soap note

Name: 

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”. Select ONE complaint that you will investigate for this note. Do NOT select a routine follow-up exam, or a scheduled annual physical.

HPI: 

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH

Allergies:   

Medication Intolerances: 

Chronic Illnesses/Major traumas 

Hospitalizations/Surgeries 

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

ROS

General

Weight change, fatigue, fever, chills, night sweats,  energy level 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB 

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools 

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

   Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight        BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS in all 4 quadrants; you must designate whether the BS are normoactive, hyper, or hypo. Abdomen soft, non-tender. No hepatosplenomegaly. 

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep - pending

Special Tests

 Diagnosis

 Differential Diagnoses – List at least three possible diagnoses for the chief complaint. This is NOT a list of unrelated, multiple diagnoses the patient may have. Focus on the chief complaint.

You must include the rationales for why you are considering each differential as a possibility for this patient. Plan on two to three sentences for each differential diagnosis listed.

· 1-

· 2-

· 3-

Diagnosis – You must include how you arrived at this diagnosis. What was your thinking? You must convince me you are on the right path.

Plan/Therapeutics

· Plan:  Be specific to this patient and include the following as applicable.

· Further testing

· Medication

· Education

· Non-medication treatments

· Return to clinic

· Referrals

 Evaluation of patient encounter – The following are required components to this section of the note:

1. Self-Assessment: Answer each of the following questions:

---Was the plan of care evidence-based? How? Convince me why you are doing what you are doing.

---What did you learn? Be specific.

---Would you have changed anything in the encounter? Why or why not?

2. References to support your treatment plan – must be current and in the reference style as though you were writing a paper.