Guidelines for Focused SOAP Notes

• Label each section of the SOAP note (each body part and system).
• Do not use unnecessary words or complete sentences.
• Use Standard Abbreviations

Include only the information provided in the case study, do not add information

S: SUBJECTIVE DATA (information the patient/caregiver tells you) .

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.

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 seven variables (location, quality, severity, timing, setting, alleviating and aggravating factors, and associated signs and symptoms), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

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.

0: OBJECTIVE DATA (information you observe, lab results, chart notes).

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. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 systems for examination) : Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing.

Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT : (this is your diagnosis)
include the rationale statement which is cited. The rationale statement should include the subjective and objective information, including the lab results that support your diagnosis.

P: PLAN (this is your treatment plan) the order of the steps in the plan are very important, follow them exactly. No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention

1. medications write out the prescription including dispensing information for all prescriptions and OTC medications. Review the Prescription PPT in DOC sharing for details.
2. additional diagnostic tests include 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.
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.