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Problem-focused SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant)

May 20, 2025

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.

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