Miss Alister 2

Week 7 Problem-Focused SOAP Note

Use the format below for your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for

more information on how your assignment will be graded.

Problem-focused SOAP Note Format

Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC): A short statement about why they are there

• History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age,

gender, and why they are there (example: 23-year-old female here for...). Elaborate

using the acronym 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: any history of CA, DM, HTN, MI, CVA?

• 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

• Vital Signs

• Physical findings listed by body systems, not paragraph form- Highlight abnormal

findings

Assessment (the diagnosis)

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent

positives and negatives for each

• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological

explanation

Plan

• Dx Plan (lab, x-ray)

• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration,

and refill(s) (if any)

• Pt. Education, including specific medication teaching points

• Referral/Follow-up

• Health maintenance: including when screenings eye, dental, pap, vaccines,

immunizations, etc. are next due

Reference

• Compare care given to the patient with the National Standards of Care/National

Guidelines. Cite accordingly.

Rubric

Problem-focused SOAP Note

Problem-focused SOAP Note

Criteria Ratings Pts

This criterion is linked to a

Learning Outcome Subjective

12.5 to >11.5 pts

Accomplished

Symptom analysis is well organized, with C/C,

OLDCART, pertinent negatives, and pertinent

positives. All data needed to support the

diagnosis & differential are present. Is

complete, concise, relevant with no extraneous

data.

12.5 pts

This criterion is linked to a

Learning Outcome Objective

12.5 to >11.5 pts

Accomplished

Complete, concise, well organized and well

written and includes pertinent positive and

pertinent negative physical findings. Organized

by body system in list format. No extraneous

data.

12.5 pts

This criterion is linked to a

Learning Outcome Assessment

12.5 to >11.5 pts

Accomplished

Diagnosis and differential dx are correct with

ICD code and supported by subjective and

objective data.

12.5 pts

This criterion is linked to a

Learning Outcome Plan

12.5 to >11.5 pts

Accomplished

Plan is organized, complete and evidence-

based according to National Standards of

Care. Addresses each diagnosis and is

individualized to the specific patient and

includes medication teaching and all 5

components: (Dx plan, Tx plan, patient

education, referral/follow-up, health

maintenance).

12.5 pts

Total Points: 50

The case

19 yrs old Asian male, university student the first grade

Chief complaint: fatigue and insomnia for one month. Sleep about 5 hours. Wake up 1~2 times

in the middle of sleep.

5’7” 166lb V/S: WNL No Allergy

DX: fatigue, unspecified

DX: Depression

DX: Anxiety

You can change DX anyway I need working DX and differential DX