PROBLEM FOCUSED SOAP NOTE

Complete a problem – focused SOAP note. Please follow the template attached. Case will be provided

Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)
• History of Present Illness (HPI) in paragraph form (remember 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 as applicable

• Family Hx: As applicable
• 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

Assessment (Diagnosis/ICD10 Code)

• Include all diagnoses that apply for this visit

Plan

• Dx Plan (lab, x-ray)

• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance (including when screenings, immunizations, etc., are next due):