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OLDCARTS SOAP NOTE REFERENCE:

Identifying information: (PATIENT’s age, gender – No NAMES)

SUBJECTIVE:

Chief complaint: Why is patient here today? Is often a quote. Include duration.

History of Present Illness (HPI): Think of it as the patient’s story. It should be

sequential; a chronological description of the patient’s illness or presenting
problem (cc). Must include each element of OLDCARTS.

Past Medical History (PMHx): Include chronic diseases and any conditions
related to the CC. If no chronic diseases, document “Denies any history of chronic
diseases”. Include hospitalizations, surgeries, GTPAL if pertinent.

**ALWAYS include medications and allergies.**

Medications: Include Rx’d meds, herbal medication, supplements, and any other
OTC meds. Include RX format and time of last dose (i.e. 9am this morning vs. 3 days
or 2 months ago).

Allergies: Drug/Food/Environmental AND must include specific reaction types

Immunizations: Is the patient up-to-date? What are the typical vaccinations for
this patient’s individual/travel/lifestyle needs AND developmental/age needs?

Please list and attest to whether or not they are up to date:

Example: 65 year old patient should have the following vaccines:

All adults ages 19 to 26 years should have the following documented here or may
include in the Assessment/Plan section for wellness or appropriate
recommendations for follow up visits:

 Varicella – denies and admits to childhood illness instead of vaccination,

date unknown, titers not available/needed at this time.
 Hep. B series - childhood records indicate up to date, unsure of dates

 HPV – not available to patient when they were of age, patient doesn’t need
at this time per guidelines.

 MMR – childhood records indicate up to date, unsure of dates

 Meningitis – was not vaccinated as a child and limited risk, not needed at
this time.

 COVID-19 vaccine – Oct. 2022, needs or refused booster

 annual Flu vaccine (influenza) – Oct. 2023

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 50-65 years and up individuals should also add:

o Pneumococcal vaccine

o Shingles vaccine (zoster)

o Tdap (tetanus, diphtheria, and whooping cough) or Td (tetanus and

diphtheria) Booster every 10 years

o RSV
 LESS LIKELY TO NEED UNLESS: Individuals who work with at-risk children or
travel internationally should include:
o Hep A series
 RARE EXAMPLE: People who interact with, or are at higher risk to interact,
with mammals other than bats that could be rabid, for a period longer than
three years after they receive PrEP. AKA an individual traveling to an
international country and they will be living in a situation where they could
come in close contact with bats or other rabid animals.
o Rabies Vaccine

Family Medical History (FMHx): Always ask pt. about FMHx of HTN, heart
disease (CAD/MI), CVA, DM, cancer (“Big Five”) and any conditions that may be
related to the HPI. If pt. denies having any FMHx to the above, document “Pt.
denies having any FMHx of HTN, heart disease (CAD/MI), CVA, DM or cancer”.

Birth History: Include in any patient under the age of 2 years or when relevant
in an older patient. Document any significant pre-pregnancy and prenatal
findings in the mother including accessibility to prenatal care. What were the
results of the post-partum depression screen if completed at this visit or a recent
visit?

Social History (SHx): Include use of ETOH, tobacco, recreational drugs, living
arrangements and occupation/education. Also include prescriptive level
documentation of sleep, diet, exercise, safety, and growth and development if
pertinent.

Ex: Patient admits to 6-8 hours of sleep a night, without difficulties falling,
staying or waking up during the night. Patient admits to overall balanced diet
following the DASH/mediter diet 24 hours recall included

Review of Systems (ROS):

1. Always include “General” as your first system and DO NOT repeat

information that you included in the HPI. Head to toe format. Any
abnormal findings should be evaluated with OLDCARTS in HPI.
2. Pick between two and nine systems- do NOT include full ROS for a
Problem Focused Visit (per CPT guidelines for an Extended ROS). Any
positives will need to be fully explored as possibly as separate
complaint:
Example:
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General: Denies fever, chills, malaise, weight loss/gain or fatigue

GI: See HPI. Denies nausea, vomiting, diarrhea, or constipation. (do not
double chart with info already included in the HPI).
GU: Denies vaginal discharge, vaginal lesions, flank pain or Hx of STI’s.
Menses: LMP started on _____ (date), 28 days from previous
menstrual cycle; “normal” flow and lasted 5 days.

3. Remember to include any possible co-morbidity questions for chronic

illness/conditions related to your follow-up.
OBJECTIVE (Physical Examination):

Include appropriate systems. Regardless of order of exam, report head to toe.

ALWAYS include vital signs and General Survey. VS
Vital Signs:
General Survey:
should include the method, location, and other specific
HEENT: objective measurement parameters. (ie. BP: Right arm,
Cardiovascular: auto, mmHg)
Respiratory:
Abdomen: If problem focused SOAP note include: only relevant
GU: systems and should match the ROS systems since they
Neuro:
were relevant there.
Musculoskeletal:

Derm: (if not covered elsewhere. I.e. swelling or color discussed in vascular
section)
Psych: HEEADSSS Assessment: This can be completed on any patient 11-18
years. Be sure to include all 8 elements. If a depression screen was completed
document that as well here such as PHQ-9.
Diagnostic Tests: Only those for which you have results. Those for which you
do not yet have results are included in Plan.

**If you have the results by the time you submit this SOAP note or they are
needed to support your plan but resulted on another day (aka an addendum
or in the results section), even if they were not resulted on the day you
physically saw the patient, include here so that it makes sense why you are
doing the plan that you are doing.

**If you are truly waiting on the results then write the plan that way, if the
results show this _______, then the plan is this ________. Or we are waiting on
the results of ____ before starting or stopping ____.

ASSESSMENT:

This includes your assessment statement and differential diagnoses.

The assessment statement is a 2-3 sentence statement summarizing the

pertinent findings from the history and physical exam that support primary
diagnosis and should include your impressions and your interpretation of all the
above information, and also draw from any clinical professional knowledge or
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DSM criteria/therapeutic models to arrive at a diagnosis. You will want to

include an in-text citation and a reference to support your decision
here.

This is your opportunity to show how you are thinking about the case
and differential diagnoses.

List your differential diagnoses: DDx would not normally be charted but for
purposes of this learning exercise, it should be included here as bulleted list.
Include a discussion of the differential diagnosis and your clinical reasoning.
Support your reasoning with findings from your history, physical, and work-up,
and information you gathered from your reading.
Prioritized Differential Diagnoses: Include the ICD 10 Codes that
correspond and make it as narrow as possible

Tier 1: The Most Likely or Primary Diagnosis: Include a statement explaining

why it is Tier 1 with rationale, pertinent +/- findings, and citation. Ex: acute
bacterial rhinosinusitis of maxillary sinus is ICD 10 J0100

Tier 2: Serious/Can’t Miss/LIFE THREATENING/URGENT/EMERGENT Diagnosis

or Diagnoses: Include a statement explaining why it is a Tier 2 Dx with
rationale, pertinent +/- findings, and citation. Ex: Influenza due to
identified novel influenza A virus with other respiratory
manifestations J09X2

Tier 3: Secondary or Less Probable Diagnoses: Include a statement

explaining why it is Tier 3 with rationale, pertinent +/- findings, and citation.
Ex: Acute nasopharyngitis [common cold] J00

PLAN:

Dx/Tx (any diagnostic tests or treatments):

Casts, splints, wart removal, IUD insertion etc. Include any tests for which you do
not yet have results:
 “Strep DNA to LabCorp” or “Pap pending”
 If you are unable to get the result before the assignment is due, state
what you plan to do if the result was positive: _____ and negative:
________.

RX: Prescription medications with correct and full sig including name of med;
##mg; route, dosing instructions, number of pills or mLs to dispense. Example:
“Amoxicillin 875mg tablet by mouth. One tablet every 12 hours x 10 days. Dispense
20 tablets/capsules/etc. # of refills.

 Think about the population, number of doses, etc. Consider what would
be best therapeutically and practically for the patient.
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 If you did not follow EBP, explain! If you would have done something
different from your preceptor, explain!

Non-prescription medications: Ibuprofen, topical OTC products, etc. – include it

as a RX format including mg, route, etc.

Pt Ed: Be thorough in your instructions to your patient (NPs are known for their
ability to educate their patients, so practice this in your practicum setting and
documentation in this section). These should also be prescriptive in nature.
Instructions to patient should be clear, concise, and likely measurable (increase
fluids to at least 64 oz each day, avoid full bladder, avoid alcohol and spicy foods,
avoid eating two hours before bedtime, elevate R leg whenever possible and
apply ice to R ankle for 20 minutes three to four times each day, etc.).

Referral/Consultations: Did you recommend patient go to ER? Derm? Did you

get a specialist to consult?

Disposition/Follow Up: What is next? When should patient comeback?

RTC in two weeks vs. three months for follow up on this condition/illness? Include
“Pt. verbalized understanding and agreed with plan.
AND
Include urgent/emergent/worsening follow up statement. This should include
explicit warning signs in patient level terms:
 “Follow up with immediately with the ER if any symptoms worsen at any time
or include new symptoms including but not limited to: (localized infection) red
streaks up from the infected site, flu-like symptoms: chills, fever, body aches,
etc. or (URI) “chest pain, shortness of breath, difficulty breathing, changes in
consciousness, neck stiffness, the worse headache of your life, etc.”
 “RTC if no improvement in 48 hours” or
 “RTC immediately if anything changes such as new symptoms: redness,
swelling or discharge”. If you are unable to get an appointment with our clinic
through the front desk, discuss options through our nurse line or go to urgent
care/ER as necessary.

DO NOT FORGET TO CONSIDER SDOH UNCOVERED IN THE HISTORY

WHEN MAKING YOUR PLAN. Must have one SDOH for each SOAP note or
discuss the patient was screened and did not have any SDOH needs. Ex: Patient
has issues with paying for medications due to lack of insurance after losing their
job recently, so you have connected them to local resources (list them) for basic
needs and discussed them with the plan of care. This is why you chose X
medication because it is less than $5 for 90 day supply at X pharmacy.

Self-study- must identify one area for self-study related to your SOAP note.

Reference(s): At least one reference should be used for every SOAP note and be
written APA format at the end of your write-up. APA in-text citations are also
expected in the assessment and plan sections.
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