wellchild soap note

STUDENTS: When using this template, erase all items in blue and in parenthesis. This is only one of hundreds of templates available. This is an academic SOAP note. In clinic, the note format will be dictated by the organization’s EMR. Nonetheless, all the information is present, and it is still a SOAP note.

ERASE ALL THE FORMATTING IN BLUE - THEY ARE DIRECTIONS

Subjective

ID: Include info such as initials, DOB and age, race, gender, whether the patient is a reliable source, and how they came to the clinic (alone/ accompanied by spouse, etc.) Some clinicians write a statement about their overall reliability as a historian/recorder of their information. To protect confidentiality, please use a made up DOB and initials.

CC: ALWAYS in patient’s own words. Use quotations.

Example: CC: “I’m here for a cough” or “annual check up” or “my throat hurts”

HPI Write this out in Paragraph form , not bullets. Include all the elements of HPI.

“OLDCARTS”

Onset/timing

Location

Duration

Context/Setting & Characteristics (i.e. Quality)

Aggravating factors and Associated Symptoms

Relieving factors

Treatments tried/Modifying Factors

Severity

Example:

HPI : Jillian X, a 63 year old white Jewish female, is here for her annual wellness visit. She states that she is in overall average physical health and her last physical was mo/d/2018. Her last mammogram was x/xx/20xx and last pap smear was x/xx/20xx, both normal. Jillian has had most normal health screenings as advised, and her last cholesterol levels were done on x/x/20xx and normal. She admits she has never had a colonoscopy. Her current complaint list includes a runny nose and ear pain that began 3 weeks ago (8/19/2019) and occurs intermittently. She has used aloe vera homemade remedy and feels relieved from her remedy within in 20 min. The symptoms were not so severe as to cause her to seek treatment (those she report ear ache as 8-9/10) but she felt she was able to handle them at home. She has no other complaints at this time.

If they are seeing you for a well exam, and have no complaints identified later in the ROS, then write up why they are here, the date of their last physical, any concerns they have, and also write up mo/year of last screening tests. There is an example in week 1 powerpoint lecture.

PMH

Medical Problem list:(diabetes, asthma, HTN, etc)

Surgeries and hospitalizations (include mo/year ):

Immunizations: (including annual flu vaccine, for older people PNA and shingles vaccine)

Allergies: (food, drug, environmental, and the reaction)

Medications (Rx and OTC, supplements and herbal)

Family History (use abbreviations - MGM, FGM, FGF, etc. ask about siblings and children. Include ages of parents and relatives at the age they passed away)

Chemicals: (including ETOH, tobacco/nicotine, drugs)

Diet/exercise/caffeine (general diet - vegetarian? Red meat? Fast food and how often), exercise- what form, how long and often)

Sexual/Reproductive History LMP, contraception and protection, birth history (can also go up in PMH/surgeries if c-section), STI history, partners, orientation)

Social History :

Occupation,marital/relationship/military status & current living situation: THis should be obvious. For living situation, make sure to include whether house, apartment, hotel, shelter, etc.

Spiritual/Social Supports: (indicate religious affiliation if they have one, major belief systems, community or other social support)

Safety: Helmets, seatbelts, texting/drinking and driving, does the patient own guns? Keep them locked? Own a pool on property? Any history of domestic violence/partner violence?

ADLs/IADLs/AADLs: (for geriatrics or adults with disabilities)

Review of Systems (these are the official 14 systems used for Evaluation and Management Services (EMS) recognized by DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services). These are usually listed as negatives and positives after each system heading, but some providers write it out as a paragraph. Samples of things you can write here are found in Bates’ guide to Physical Assessment and History Taking, on page 12 and 13.

· Constitutional

· Eyes

· Ears, Nose, Throat

· Cardiovascular

· Respiratory

· Gastrointestinal

· Genitourinary

· Musculoskeletal

· Integumentary/Breast

· Neurologic

· Psychiatric

· Hematologic/Lymphatic

· Endocrine

· Allergic/Immunologic

Objective

Physical Exam:

Vital Signs along with height, weight, BMI (and for children < 2, head circumference and length vs height)

Only include what is pertinent to the problem. WNL or “denies” is not acceptable.

Physical

General survey:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

CV:

Pulm:

Abdomen/GI:

GU:

M/S:

Lymph:

Skin:

Neuro:

Psych:

Assessment:

Differential Diagnosis (this is your critical thinking analysis of all the subjective and objective data)

1 (and a brief reason why you ruled it in/out)

2 (and a brief reason why you ruled it in/out)

3 (and a brief reason why you ruled it in/out) - at least 3 minimum should be on all your notes

4 (and a brief reason why you ruled it in/out)

5 (and a brief reason why you ruled it in/out)

Diagnosis: Above list is your differentials. Choose one and make sure you indicate your final diagnosis somehow. Don’t leave other providers guessing which one you chose.

Plan:

-Diagnostic Plan (xrays, labs, PFTs, etc): Be specific. Do not write “blood work” or Xray. Write out specific type of Xray and body part, scan, US, or lab you want drawn.

Therapeutic Plan (meds): You need to be specific. The longer you are in clinicals, the more is expected. For this course, at minimum provide drug name, dosage, timing.

In future clinicals you will be expected to write out concentration (as applies for certain drugs), # dispensed, and any refills.

ProTip: Ask your patient what pharmacy they prefer. Usually most EMRs have a spot for it. Make sure the drug is covered by their insurance, on formulary = cheaper.

-Referrals

As needed to specialists, dieticians, physical therapy, mental health, ER, support groups, etc.

-Education and Follow up Plan: (Give patient specific instructions on when to f/u and include when to RTC sooner if worse, or when to go to ER and document this education in your note. Also discuss and document medications - reasons for prescribing, doses, how to take it, and expected side effects. Make sure to tell pt when to go to lab, and if it’s fasting lab. Document it all).