W5 Problem Focused Soap Note

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