fill out template. use this for soap note
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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.
