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Guidelines For Complete SOAP2

1) This document provides guidelines for writing a complete SOAP note, including the required elements for each section and the points allocated to each element. 2) The subjective (S) section should include the chief complaint, history of present illness, past medical history, current health status, family history, and review of systems. 3) The objective (O) section includes general appearance, vital signs, physical exam findings, and current lab results. 4) The assessment (A) section lists differential diagnoses, final diagnosis with supporting evidence, and chronic health problems. 5) The plan (P) section outlines diagnostic tests, treatment, patient education, and follow-up

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Betsy Brown Byersmith
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159 views2 pages

Guidelines For Complete SOAP2

1) This document provides guidelines for writing a complete SOAP note, including the required elements for each section and the points allocated to each element. 2) The subjective (S) section should include the chief complaint, history of present illness, past medical history, current health status, family history, and review of systems. 3) The objective (O) section includes general appearance, vital signs, physical exam findings, and current lab results. 4) The assessment (A) section lists differential diagnoses, final diagnosis with supporting evidence, and chronic health problems. 5) The plan (P) section outlines diagnostic tests, treatment, patient education, and follow-up

Uploaded by

Betsy Brown Byersmith
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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1

Guidelines for Complete Written SOAP Notes

STUDENT NAME:
Provide information: episodic or complete, SOAP note # ____, semester and year
Date of patient encounter:
Patient age and gender:
Points
S: (subjective data) 25%

CC: (chief complaint): Reason for the patient visit – What brings patient
to seek medical attention? If possible, put in patient’s
words or paraphrase 2

HPI: (history of present


illness): Tells the story of the chief complaint using the
seven variables (location, quality, quantity,
chronology, setting, aggravating and alleviating
factors, associated manifestations) 4

PMH: (past medical history): Includes serious illnesses, accidents & hospitalizations
(include dates & names of hospitals);
if female: OB/GYN history, including LMP 3

Current Health Status: 5

1. Allergies – substance or medication; state what the allergic reaction entails


2. Tobacco – type, amount, pack years
3. Alcohol use—type, amount, frequency
4. Illegal drugs – type, amount, past usage
5. Current medications – prescribed, OTC, herbals, reasons for use for each
6. Injuries – dates, type, residual effects
7. Environmental hazards – home, work, school
8. Screening tests – test, date, results (this includes hearing, vision,
mammograms, testicular exams, etc—not screening labs or diagnostic
tests ordered by a provider)
9. Safety measures employed on a regular basis– seat belts, bike helmets, other
10. Immunizations – type, date
11. Exercise & leisure – type, frequency, duration
12. Sleep – patterns for retiring, awakening, naps, difficulties reported
13. Diet – recall, restrictions, supplements, caffeine

FH: (family history): Include history of chronic disease & risk factors 3
(for example – MI < 50, cancer, glaucoma) in
parents &siblings. Illustrate with a genogram*. 8
[*genogram information is found in Bates text –
pages 9-10 but you should construct the
genogram back three generations from the
specific patient you are assessing. A clear legend
for the genogram must also be included]

SH: (social history): Include marital status, #of dependents, sexual 3


history (include history of HIV risk factors such
as STDs, # of lifetime partners, IV drug use, use of
condoms, sexual orientation). Include a developmental
assessment.

ROS: (review of systems) See Bates p. 10-13. Include pertinent positives.


2

O: (objective data) 25%

General appearance – statement that should include patient 3


information – see text for examples

Vital signs (include TPR, BP [left or right arm, sitting or standing, size cuff],
height & weight). Calculate BMI—state over or under ideal weight. 2

PE: (physical exam): Should be complete with special attention to areas 15


suggested by history.

Present lab: Results available during visit (such as H & H, wet prep, 2
Hemocults, etc)

A: Assessment 20%

Differential diagnoses: List of possible diagnoses related to CC 5


( should include 3 to 4 of the most likely diagnoses for
the chief complaint) and list the ICD-10 codes for each

*****Do not use “Rule out” diagnosis.

Then, list the final/presumptive diagnosis with ICD10 code, for this visit 10
and highlight data that support your decision (ROS information, PE
findings, lab results, diagnostic tests done).

Now, list the chronic health problems (if the patient has any) with ICD-10 codes as 5
a problem list. (example:1. hypertension – controlled,2. hyperlipidemia – controlled,
3. diabetes mellitus – uncontrolled, etc.). If the patient has no chronic health problems,
please make this statement.

P: Plan –the plan is mainly for the presumptive diagnosis but include 30%
others if needed

DX: diagnostic and/or screening tests pending or ordered (labs, x-rays, etc.) 5

TX: treatment for the problem/CC. Should include medication (with generic and trade 5
name, dose, route, duration of therapy), supportive treatments (physical therapy,
counseling, etc.). Include patient responsibilities in his/her own care (such as dressing
changes, BP diary, diet diary, etc).

ED: Patient teaching: should include teaching of medication ordered above (any and 10
all information that should be provided to the patient so that the patient can optimize
therapy), health counseling, when to call the provider (worrisome signs/symptoms).
Education should include health maintenance discussions at each and every visit,
so your documentation should be sure to address all health maintenance issues for
this patient—such as smoking cessation, diet, immunizations, blood sugar checks,
regular screenings (mammogram, testicular exams, PAP testing, etc).

RTC: specific instructions on when to return for follow up or management plans. If this 10
is an acute, self-limiting problem, there may be a suggestion for follow up if the problem
does not resolve. If the patient has existing chronic health problems (hypertension,
hyperlipidemia, etc.) then there should be a plan to address those issues. List each chronic health
problem, then the general plan for management and follow up.

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