Health Assessment Interview

SOAP note template

SOAP

SUBJECTIVE:

ID: 

CC:  “                            “

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY

PAST MEDICAL PROCEDURES

MEDICATIONS

ALLERGIES

LMP (as applies)

FAMILY HISTORY

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE  

-TOBACCO USE/Vaping: 

-ALCOHOL USE: social drinker 

-DRUG USE: 

-MARITAL HISTORY: 

-OCCUPATION:

-EXERCISE/DIET: 

-SLEEP/STRESS: 

IMMUNIZATIONS

SPIRITUAL AFFILIATION

REVIEW OF SYSTEMS:

 ONLY DOCUMENT WHAT YOU ASKED ABOUT

DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked. 

CONSTITUTIONAL:  denies fever, chills, and loss of appetite, fatigue, or weight loss

EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)

EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)

CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea. 

RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.

GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.

GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain,  or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction

MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM. 

INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.

NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss

PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts 

ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance

HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes

ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover

OBJECTIVE:      

VITAL SIGNS:  P:  BP:   RR:     T: 97.8  SpO2  RA:     Pain : /10    

Ht :     Wt :     BMI: 

PHYSICAL EXAM: GENERAL survey:  

 

HEENT:  

Head  

Eyes

Ears 

Nose 

Throat

Mouth   

·      

HEART: 

RESPIRATORY: 

CHEST/BREASTS:

GI:

GU:

LYMPH:

MUSCULOSKELETAL/EXTREMITIES:  

SKIN: 

NEUROLOGIC:

PSYCHIATRIC:

ASSESSMENT:

Differential Diagnosis:

1. One possible dx with rationale on why you ruled out

2. Another 

3. A third (minimum = three)

4. A fourth

FINAL DX: The chosen diagnosis from above

PLAN:

-Diagnostic plan (labs/xrays/EKG etc.)

-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation

-Referrals

-Education 

-F/U plan