General Guidelines:
- Label each section of the SOAP note (each body part and system).
- Do not use unnecessary words or complete sentences.
- Use Standard Abbreviations
- All Heading and Subheadings must be bolded and separate, no narrative ROS or Physical (Paragraph Form)
All Soap Notes must include:
- Title with Soap # and Main Diagnosis (Soap # 10. Dx: Major depressive disorder, recurrent, moderate(F33.1)
- Full name of student
- Date of encounter
- Name of Preceptor
- Name of the Clinical Instructor
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Identifying Information: The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes.
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in “quotes”. . If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, and hospitalizations allergies, age-appropriate immunization status.
Past Surgical History (PSH): operations and procedures. (“None or no past surgical history”–if no surgical history)
Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9- }.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
All Sections must be included in all soap notes
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described
Record observations for the following systems for each patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vital signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
There must be ONE main Diagnosis
Remember: Your subjective and objective data should support your diagnoses and therapeutic plan.
Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).
For the main diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
Must include a Minimum of 3 differential diagnosis with ICD codes and a paragraph for each diagnosis that includes a definition of the differential diagnosis, common signs and symptoms, tests results and citations. Minimum 3 differential diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation. (in-text citation)
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications. Include at least 3 side effects of the medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs
to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.
6. References: Notes must have Minimum of 3 Scholarly References ( Journals, Books, and Studies), APA Style.