focused note

Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints

45 y/o male presents to clinic complaining of left knee pain.

Dx: OA of left knee

Use the format below for your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.

Problem-focused SOAP Note 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. 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)
• 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.

Rubric

Problem-focused SOAP Note (1)

15 pts

15 pts

15 pts