When completing your SOAP note:
• Your patient should be at least 50 years old and have at least one chronic health problem.
• Be sure to complete ALL parts of the plan, whether they apply or not. For example, if you do not need to assess a particular system, write “Deferred” in the associated blank. For another example, if it is not necessary to refer your patient, be sure to write “None” next to referral. In sum, do not leave blanks on any parts of the plan!
• Do NOT document “WNL” (within normal limits) or “unremarkable.” Be sure to describe your findings appropriately, even if normal.
• You should use at least two scholarly resources to obtain the necessary clinical information to develop the assessment and treatment plan. Format your references in APA format.
• Refer to the assignment rubric prior for more specific details.
1. Patients initials/ Age/ gender/ marital status/ ethnicity/ religion/ occupation/ language/military status
2. Chief complaint: Succinctly state the patients chief complaint
3. History of Present Illness (HPI): In this section address OLDCARTS and any other information pertinent to the complaint. You will write this in paragraph form.
4. Differential Diagnoses: Start thinking about the complaint. Decide what systems to review in the ROS (review of the systems). Give the most likely diagnosis first and then go from there. Look over these and use them to decide what other questions you might ask. Use scholarly resources as references.
5. Review of the system (ROS): In this section, list all systems for review to help gather more information on the patients symptoms. Think short answers.
– Chest/ Respiratory/Cardiac:
– Peripheral Vascular
– Mental status
6- Medications: what medications is the patient taking? Dosages? Why?
7- Allergies: What allergies (and associated reaction) does the patient have (medication, food and environmental)?
8- Past medical history: list any medical diagnoses or ongoing problems the patient may have including chronic diseases.
10- Screening tests (for health maintenance)
11- Family history
12- Social history
1-Individual systems: The rest of the information in this section is based upon the systems you identified previously as being important to examine due to the HPI and ROS and the differential diagnoses. The “general” system describes the overall look of that patient (e.g. “no acute distress”, etc.) This is not a narrative format but is just listing the facts.
– Lab test/ Xray- Results: list the labs or xrays you ordered for which you have results. If you did not receive results, then the pending labs/xrays belong in the “diagnostics” portion of the plan. For example, if you ordered a CBC blood test and do not have results, list CBC in the “Diagnostics” portion of the plan and the fact that is pending in that section. Be sure to include your follow up that will follow up with the labs/xrays that are pending.
– Procedures : In this section, list any procedures you completed during the exam.
– Assessment: In this section, list the diagnoses pertinent to the patient. Include the correct ICD 10 code.
– Plan: it is essential you have six portions in your plan for your diagnosis. If you have more than one diagnosis, then list the six categories for each diagnosis.
– 1-Pharmacologic: In this section list any medications prescribed or recommended dosages and amount of time the patient will take it.
– 2- Non pharmacologic: In this section, list any interventions you have recommended not relating to prescribing or recommending medications.
– 3- Diagnostics: List any labs that you ordered for which you don’t have results yet, including pending labs. If you ordered xrays or planned procedures for which you do not yet have results or have not performed yet, you also list them here.
– 4- Patient education: In this section, list any education you give the patient for specific diagnosis.
– 5- Referrals: In this section, list any referrals for the patient. If there are none, list “none at this time”
– 6- Health Maintenance/ Follow up: In this section, list when you would like the patient to follow up ( do not forget to mention you will follow up with any pending labs or tests). Additionally, list and health maintenance issues you identified while the patient was here (for example recommending a complete physical exam, etc)
– 7- References: Use at least 2 scholarly references to support your diagnosis and plan.
ICD 10: enter an accurate code. Please note that your documentation must support the code.
Diagnosis : Enter your diagnosis in this section.