678

Week 2 Problem-focused SOAP Note

Problem-focused SOAP Note Format

Demographic Data

• Patient initial (one initial only), age, and gender must be HIPAA compliant.

Subjective

• Chief Complaint (CC)

• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location,

Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)

• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications,

allergies, iImmunizations, and preventative health maintenance

• Family Hx

• 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

• Physical findings listed by body systems, not paragraph form

Assessment (the diagnosis)

• Three (3) differential diagnosis (if applicable) with rationale

• Final diagnosis with rationale and pathophysiological explanation

Plan

• Dx Plan (lab, x-ray)

• Tx Plan (meds)

• Pt. Education, including specific medication teaching points

• Referral/Follow-up

• Health maintenance (including when screenings, immunizations, etc., are next due):

Reference

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

Guidelines. Cite accordingly.

The case working diagnosis: ICD-10 code Z34. 9 for Encounter for supervision of normal

pregnancy, unspecified

Gestation 13 weeks OB(obstetric) visit

36 yrs old female

G2P1(two times pregnancy one living child)

EDD: 07/22/2023 (expected delivery date)

Allergy: Sulfa

The first child was born by cesarean section

African American

Medication list

Fish oil one-tab daily PO

Aspirin 81mg PO daily

Progesterone micronized 200mg PO daily

Doxylamine-pyridoxine 10-10 mg one-tab daily PO

Folic acid 1mg PO daily

Test done

Hemoglobin A1c

Vitamin B12

Urinalysis and urine culture

Obstetric panel

Drug profile

TSH, T3, T4 (Thyroid panel)

Vitamin D

Ultrasound for OB first trimester

Surgical history: Dilatation and curettage and abortion: The code descriptor for 69.02

Cesarean section

179 pounds 67 inch height