SOAP note

Submita problem-focused SOAP note. I provided a format. Please follow that.

CASE: 62 year old female came into the clinic with complaints of fatigue, weakness, numbness/tingling in hands and feet, difficulty thinking and lightheadedness for the past few weeks. The patient does not have a history of any neurological disorders. PMH of hypertension and hyperlipidemia.

PLEASE USE B12 DEFICIENCY AS WORKING DIAGNOSIS.

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)

Reference

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