Executive Solution Overview
**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 th…
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**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.
– 2 years ago