Problem-focused SOAP Note
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)
- Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological
explanation - At least Two (2) differential diagnoses (if applicable) with rationale and pertinent
positives and negatives for each
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
Make pediatric soap note. Below is an example, but you can change it. However, it needs one working diagnosis with two different differential diagnoses with rationale and pertinent positives and negatives for each. Plus ICD 10 code and cpt code.
Example case
16 yrs old male: All labs are WNL. Complains chronic Acne on face, fatigue, insomnia. Spanish speaking, Low income. Playing video games almost all night. Prescribed Doxycycline 100mg PO BID for two weeks no refill, Clindamycin 1% topical lotion twice a day 60 gram no refill, and hydrogen peroxide gel for acne as prn with 2 times refills. Told mom not to play video games at night. However, you can change the case to other pediatric cases such as UTI, dermatitis, pruritus etc.
