CHA AHP

SOAP Notes Guidelines

Subjective:

ID: Initials, age and gender only

Source: Who is giving information and their reliability

CC: Must be in pt own words and in quotes. One to two sentences maximum.

HPI: Fully describe the acute symptoms. Use acronym OLDCHARTS to fully describe the

symptoms presented in the CC

PMH:

Current Medications: list all meds including OTC and Herbal. Give dose, route and frequency.

Don’t include meds used to treat the acute symptoms mentioned in the HPI. OK to say “none” if

none

Disease Processes: list all diseases with date of diagnosis. OK to say “none” if appropriate.

Hospitalizations and Surgeries: List all with dates. OK to say “none” if appropriate.

Allergies: List all with typical reaction when exposed. Include environmental and food allergies.

If none, you need to say “no drug, food or environmental allergies”.

FH: *Only complete if the complaint logically leads to questions about family history. Can be

abbreviated. If bit relevant, say “non-contributory”.

ROS: Use textbook to address hx r/t symptoms associated with the system. Don’t repeat HPI-

should be hx of system before onset of acute symptoms. Is ok to say “see HPI for acute

symptoms” if you feel the need to refer to the acute symptoms but is not necessary.

Psych/Social: Include issues regarding habits, insurance, coping, stress here. For Children

include a statement about their growth and development. If school age- indicate how they are

doing in school.

Immunizations/Infectious Diseases: *Only complete if the complaint logically leads to questions

about Immunizations and communicable diseases. Can be abbreviated. For Children- indicate if

current on their immunizations. OK to say “none” if appropriate.

Violence Hx. – Domestic or environmental violence- Bullying for school age

Objective: BP: ____ P: ___ R: ___ Temp: ___ BMI: ____Ht: ___, Wt ___lbs.

(Children only- Include CDC growth chart)

Include entire assessment as described in your textbook for the system we are studying that

week.

Assessment: Medical diagnosis- plus 2 or 3 differential diagnoses

Plan: Provide complete medical and nursing plan of care. Must provide reference for your plan

in APA format. Faculty will provide references for abnormal findings.

References