Soap notes

Patient Demographics

Chief Complaint

Assessment and Interventions Done Today

Include age, gender, ethnicity, occupation and other demographics, who they live with, location, housing, PMH/PSH, medications and purpose, allergies pertinent to the health status.

Identify why the patient is at the site today. When possible use the patient’s words/chief complaint.

Use SOAP format for the assessment data following a head-to-toe assessment, when applicable. Identify interventions done today, and anticipated before or @ next visit (e.g., procedures employed, medications prescribed, patient education, referrals or support systems enacted). Interventions should relate to the reason for the visit as well as the health risk, health alteration and demographics of the patient. Include medical and nursing dx.

Demographics:

PMH:

PSH:

Allergies:

Medications:

S

O:

A:

Medical Diagnosis

Nursing Diagnosis:

P:

Additional Information

Self-evaluation/summary