SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data (20 pts.)
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Past Medical History:
Social History (alcohol, drug, or tobacco use):
Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI)
Objective Data (25 pts.)
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. If it is a child, include the Tanner stage. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
Assessment (20 pts.)
A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
PLAN (25 pts.)
1. Prescriptions with dosage, route, duration, amount prescribed, and if
refills are provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
Cultural Diversity: What cultural considerations would you suggest for this patient?
Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit.
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
APA Format (10 pts.)
Include a title page and references with all of your papers. There should be at least four references from textbooks, journal articles, CDC or NIH that are not older than 5 years. Please do not use Wikipedia, WebMD, dictionaries, or any websites that are not evidence based.
EXAMPLE DOCUMENT ONLY REFERENCE TOOL
Chief Complaint: ___ year (month) old male (female) present with _______________ x _____ days (months).
History of Present Illness: Health and behavior prior to onset of symptoms; epidemiology; any therapies tried by parents or PMD.
Previous Medical History:
Birth History: Gestational age, cesarean versus vaginal, GxPx of mother, prenatal course (meds, infections, fetal activity), delivery, neonatal course (home with mom? feeding, fevers).
Feeding History (if infant): how often and what content.
Growth and Development: growth curves and motor milestones (too short, too tall, too heavy, too thin, bottle/cup, toilet training, school performance, interactive skills and independence, sleep habits, elimination habits).
Social History: household, planned pregnancy?, peers, smoke, sexual activity.
Hospitalizations and Surgeries:
History of urinary tract infections or otitis media:
Family History: Parents, ages, jobs, illnesses and meds, ages of grandparents, siblings. Any history of congenital or childhood illnesses, seizure disorders, diabetes, mental retardation, or other conditions.
Parental Concerns: (if any)
Review of Systems:
Skin: rashes, hair, birthmarks
Neuro: changes in mental status, headaches, loss of consciousness, ataxia, dizziness, tingling, numbness
ENT: glasses, snoring, teeth, malocclusion, orthodontia
Cardiovascular/Respiratory: murmur, edema, sputum, cough
GI: nausea, vomiting, diarrhea, constipation, jaundice, belly pain
GU: frequency, dysuria, hematuria, genitalia
Musculoskeletal: joints, gait, posture
Endocrine: puberty, lethargy, polyuria, polydipsia
Miscellaneous: temperment, activity, special sensesPhysical Exam: Weight: ___ kg = (___) % ile Height ___ cm = (___) % ile Head Circumference = ___ cm = (___) % ile
Vitals signs as per _________: (with cry?) HR:___ BP:___ RR___ T____
General: A statement of patient’s condition: color, nutrition, hydration, respiration, speech, gait, alertness, cooperation, activity.
H: head shape, symmetry, hair, facial symmetry, chin, fontanelle, craniotabes
E: EOMs, pupils and iris, fundi, prominence, conjuntivae, sclera, discharge, ptosis, strabismus, nystagmus, cataracts?
E: Malformations, discharge, cerumen, tenderness, TMs, injected? mobile? landmarks, fluid level?
N: Nares (patency, turbinates), septum, secretion, color of mucous membranes, sinus tenderness
T: Mouth breather? Lips: color, eruptions, fissures; Teeth: number, caries, gums, malocclusion; Tongue: moisture, color, size; Oral lesions, mucous membranes moist? Palate: type of arch, deformity, cryptic, exudation, inflammation; Epiglottitis: color, swelling; Voice: cough, stridor.
Neck: supple, ROM, masses, cysts, nodes, trachea midline, lymph nodes, thyroid
Clavicles: crepitus, nodes, axillae
? Contour and shape: costochondral junctions. Respiration rate, depth, symmetry, distress, retractions; Pectus? breast tissue.
? Lungs: auscultation: quality of breath sounds, wheezing or crackles, transmitted sounds
percussion: fremitus where applicable. ? Heart: Inspection for pulsations; palpation for point of apex beat, thrills. Auscultation: Cover all areas of the heart. RRR? Character of the first and second heart sounds over valvular areas and apex. Third sound? Split sounds? Murmurs: time: location of greatest intensity, transmission, character, change with position. Listen for bruits over large vessels.
? Pulse: rate, volume, rhythm, fullness, femorals.
Abdomen: shape, scars? distended? soft, hard, cord, hernias, palpable loops
palpate and percuss: liver, spleen, kidneys, aortic pulse. Tympani? Fluid?
bladder percussion and tendernessGenitals: hernias, testicles descended bilaterally, circumcised?, cremasteric reflex? urethral discharge? phimosis? hypospadias? labia, hymen, perineal area. Tanner Staging, edema in newborn (esp. breech)Rectal: masses, tenderness, stools, heme test, prolapse? dimples? hemorrhoids?
Extremities pulses, edema, clubbing, cyanosis, capillary refill, muscle atrophy, stance, body deformities
joints: range of motion, pain, swelling, warmth
hips: Ortolani to relocate, Barlow to dislocateBack: spine, flank pain, L/S abnormalities
Neuro: Alert and oriented, MSE for age, speech, gait, attention, CNs, sensory, strength, DTRs, coordination
Skin: Quality: dry, moist, scaly, turgor, hydration. Color (pale, jaundice), rashes, bruises, subcutaneous fat, birth marks, eruptions, hemorrages, petechiae, desquamation, cyanosis, icterus, edema, local swelling, bites. Describe lesions, distribution, measure size, photograph if possible).
Assessment and Plan
This section should begin with a brief summary of the patient’s present status, this is usually only one paragraph. The remainder of the combined assessment and plan section is divided by systems (for example: respiratory, cardiac, FEN, renal, neuro, etc.). The patient is assessed in terms of each system and a plan is devised to address each aspect