Description Problem-Focused SOAP Note Format Demographic Data Age and gender (must be HIPAA com ...
Description Problem-Focused SOAP Note Format Demographic Data Age and gender (must be HIPAA compliant) Subjective Chief Complaint (CC): A short statement about why they are there History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for...). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance Family Hx: any history of CA, DM, HTN, MI, CVA? Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) Objective Vital Signs Physical findings listed by body systems, not paragraph form- Highlight abnormal findings Assessment (the diagnosis) At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation Plan Dx Plan (lab, x-ray) Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) Pt. Education, including specific medication teaching points Referral/Follow-up Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
