Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type of reaction/severity/date
Immunization Status: e.g. Flu, COVID, TdaP, etc.
Screenings: In this section you will document any age-appropriate screenings the patient had prior to the visit today. For example, dental visits, PAP, colorectal screening, microfilament, etc… (Indicate if results were normal or abnormal)
FMH: document genetically relevant conditions of immediate family members (parents, children, siblings, and grandparents). If history is unknown then document “history unknown” for the family member you inquired about.
Personal History/Social History: Occupation, home environment, relationship status, nutrition, exercise, and substance use (smoking, alcohol, illicit drug use)
Females: LMP and relevant OB/GYN history Gravida, Para, Abortions, Living (G__P__A__L__)
If prior pregnancies document any pregnancy or postpartum complications.
Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception
Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write either class of medication or indications for use in parentheses)
For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full ROS for a comprehensive/well exam visit.
Review of Systems:
For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI. Complete a full PE for a comprehensive/well exam visit.
Vital Signs: Blood Pressure- P- RR- T- Height- Weight- BMI-
Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.
(include APA citations)
|Pertinent Positives||Pertinent Negatives|
In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)
Include a brief summary of the visit here
(APA citations required in your plan)
In this section, you would list the diagnosis that you assessed for your patient. The Diagnosis is your primary/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.
Diagnosis ICD-10 (must be related to CC/HPI)
· Follow up
Health Maintenance: Required App for USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp
Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—tobacco cessation program, etc. even though you may not address in an episodic visit)
RTC: (Document disposition)
References (APA Format)
NUR 634 SOAP Note Rubric
|Element||Exceeds Expectations ≥ 90||Meets Expectations 83-89||Partially Meets Expectations 80-82||Does not meet Expectations ≤ 79|
|CC & History of Present Illness
Tell the “story” of the complaint
|Appropriate OPQRST, the “story” of the HPI is clear, succinct and complete||Appropriate OPQRST discussed, extraneous elements included or not succinct||Missing 1-2 pertinent elements||Missing more than 2 pertinent elements|
|Past Medical & surgical History (PMH, PSH) relevant to the HPI
Include pertinent history (with positives and negatives)
|Complete problem list of main problems with relevant PMH/PSH to the HPI explored fully
Include pertinent positives & negatives
|1 element in PMH relevant to HPI missing or not explored fully||2 elements in PMH relevant to the HPI missing||Multiple elements in PMH relevant to the HPI missing|
· If relevant, include:
· Sexual Hx
· Substance use (etoh, drugs, smoking)
|Social history relevant to the HPI covered completely||Social history missing one pertinent element||Social history missing 2 or more pertinent elements||Not addressed|
|Family history relevant to the HPI included
|Family history missing one to two pertinent elements||Family history missing more than two pertinent elements||Not addressed|
|Review of Systems
|All appropriate systems covered completely, no extraneous||All appropriate systems covered with some extraneous elements||Missing 1 appropriate system||Missing more than 1 appropriate system|
(can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)
|Appropriate based on complaint||Appropriate based on complaint with 1-2 missing systems||Appropriate based on complaint with > 3-4 missing systems||Missing > 4 elements|
|Differential Diagnosis (DDx) and Main Dx for each problem
Minimum of 3 differentials diagnosis:
Patho of the problem; pertinent positives and pertinent negatives: supported by S + O data and rationale as to why that was or was not chosen for the final Dx
|DDX and Main Dx appropriate based on findings with complete reasoning, patho and pertinent positives and negatives included; appropriate ICD-10 and CPT coding for main Dx
|Main Dx Appropriate based on findings though missing 1 key DDx
Rationale for DDX and main Dx could be better described
|Appropriate but possible better one available based on findings or missing some key elements||Inappropriate based on findings|
|Treatment Plan for each final diagnosis with diagnostics, referrals, pt education, follow-up parameters (each as needed)
Include HCM recommendations for this patient (see USPSTF for age-appropriate recommendations)
Cite reference for diagnosis and plan for each problem.
|Specific, appropriate and EBP with clear explanations for each Dx-with citations from appropriate sources||Appropriate and EBP,
Missing a few elements or explanations not clear for all Dx
Missing 1 citation
|Appropriate but not first line, or missing multiple minor components
Missing > 1 citation
|Inappropriate or missing multiple elements
* Key: CC = Chief complaint; HPI-History of Present Illness. With pain and many symptoms- an approach that is helpful is OPQRST: Symptom analysis- Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing (history). Be sure to give the “story of the symptom or complaint. However, simply listing each of these will not always tell the complete story of the HPI. Step back, read what you wrote and make sure it is clear and complete.