Problem-Focused SOAP Note Post

Problem-Focused SOAP Note Post

Format

Demographic Data

Age and gender (must be HIPAA compliant)
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. Hex (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hex: any history of CA, DM, HTN, MI, CVA?
Social Hex: Including nutrition, exercise, substance use, sexual hex, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective

Problem-Focused SOAP Note Post

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

Check tips on how to do your Nursing Assignments.

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

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

Problem-Focused SOAP Note Post

Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. 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.