Standardized SOAP Note PDF

Standardized SOAP Note  Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation of cases for healthcare providers. Subjective personal views or feelings of a patient Chief Complaint (CC) The CC or presenting problem is report...

Standardized SOAP Note  Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation of cases for healthcare providers. Subjective personal views or feelings of a patient Chief Complaint (CC) The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting to the hospital Examples: chest pain, decreased appetite, shortness of breath. History of Present Illness (HPI) The HPI begins vomiting for 3 days with a simple one line opening statement including the patient's age, sex and reason for the visit. Example: 47-year old female presenting with abdominal pain. Medical history: Pertinent current or past medical conditions Surgical history: Try to include the year of the surgery and surgeon if possible. Family history: Include pertinent family history. Social History: Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression. Subjective Review of Systems (ROS) This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient. General: Weight loss, decreased appetite Gastrointestinal: Abdominal pain, hematochezia Musculoskeletal: Toe pain, decreased right shoulder range of motion Current Medications, Allergies Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often. Example: Motrin 600 mg orally every 4 to 6 hours for 5 days Objective This section documents the objective data from the patient encounter. This includes: Vital signs Physical exam findings Laboratory data Imaging results Other diagnostic data Recognition and review of the documentation of other clinicians.  A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading. Assessment This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems. Elements include the following. Problem List the problem list in order of importance. A problem is often known as a diagnosis. Differential Diagnosis This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely. Plan This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem: Therapy needed (medications) Specialist referral(s) or consults Patient education, counseling