QUESTION

Problem-focused SOAP Note Format

Demographic Data

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)
Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

SOLUTION

Step 1: Demographic Data

Include patient age and gender only — never use identifiers like name or date of birth to maintain HIPAA compliance.
Example: “45-year-old male”

Step 2: Subjective (S)

Chief Complaint (CC): Write a concise statement of the patient’s primary reason for visit.
- Example: “CC: Persistent cough for 3 weeks.”
History of Present Illness (HPI): Write in paragraph form starting with age, gender, and reason for visit.
- Use the OLDCART acronym to provide details:
  - Onset: When did symptoms start?
  - Location: Where is the symptom/problem?
  - Duration: How long has it lasted?
  - Characteristics: What is it like (sharp, dull, constant)?
  - Aggravating/Alleviating Factors: What makes it worse or better?
  - Relieving Factors: What helps the symptom?
  - Treatment: What treatments have been tried?
- Example: “A 45-year-old male presents with a persistent dry cough that began three weeks ago. The cough is constant, worse at night, and not relieved by over-the-counter cough syrup.”
Past Medical History (PMH): Include relevant past medical and surgical history, medications, allergies, immunizations, and preventive care.
Family History: Note any history of cancer (CA), diabetes mellitus (DM), hypertension (HTN), myocardial infarction (MI), cerebrovascular accident (CVA), etc.
Social History: Include lifestyle factors such as nutrition, exercise, tobacco, alcohol, drug use, sexual history, occupation, and school.
Review of Systems (ROS): Document symptoms from other body systems as appropriate and note health maintenance (e.g., last eye exam, dental checkup, pap smear, vaccinations).

Step 3: Objective (O)

Vital Signs: List blood pressure, pulse, temperature, respiratory rate, oxygen saturation.
Physical Exam Findings: Organize by body systems (e.g., Respiratory, Cardiovascular). Use bullet points, not paragraphs. Highlight abnormal findings.
- Example:
  - Respiratory: Clear to auscultation bilaterally; no wheezes or crackles
  - Cardiovascular: Regular rate and rhythm; no murmurs

Step 4: Assessment (A)

Provide at least two differential diagnoses with rationale, including key positives and negatives that support or rule out each diagnosis.
Final diagnosis with rationale, pathophysiology, and relevant clinical findings.
- Example:
  - Differential 1: Acute bronchitis — cough, duration, absence of fever.
  - Differential 2: Postnasal drip — cough worse at night, no lung findings.
  - Final diagnosis: Acute bronchitis based on history and exam.

Step 5: Plan (P)

Diagnostic Plan: Labs, imaging, or tests ordered to confirm diagnosis or rule out others.
Treatment Plan: Medications prescribed, including dosage, frequency, duration, and refill info.
Patient Education: Specific teaching points, such as medication side effects, adherence, symptom monitoring.
Referral/Follow-up: Next appointment, specialist referral if needed.
Health Maintenance: Recommendations for screenings, immunizations, or preventive visits next due.

Step 6: Reference

Compare your patient care to National Standards or Guidelines (e.g., CDC, American Heart Association).
Cite guidelines or standards used to support your plan.
- Example: “Management consistent with CDC guidelines for acute bronchitis (CDC, 2023).”

If you follow this clear structure, your SOAP note will be organized, thorough, and aligned with clinical standards.