Problem-Focused SOAP Note Format
Demographic Data (Pediatrics ) Patient initial (one initial only), age 10 , male must be HIPAA compliant.
Subjective Chief Complaint (CC) ” I have a runny nose for the last 3 days with headaches” History of Present Illness (HPI) in paragraph form
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 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 Physical findings listed by body systems, not paragraph form Assessment (the diagnosis) Three (3) differential diagnosis (if applicable) with rationale Final diagnosis with rationale and pathophysiological explanation Plan Dx Plan (lab, x-ray) Tx Plan (meds) Pt. Education, including specific medication teaching points Referral/Follow-up Health maintenance (including when screenings, immunizations, etc., are next due): Reference Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly
Hx (pmh): medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance family hx social hx: including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
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Problem-Focused SOAP Note Format
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