soap note

Problem-Focused SOAP Note Format

Demographic Data 

• Age and gender (must be HIPAA compliant) 

Subjective 

• Chief Complaint (CC): A short statement about why they are there 
• History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for...). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment 
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance 
• Family Hx: any history of CA, DM, HTN, MI, CVA?  
• 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 

• Vital Signs 
• Physical findings listed by body systems, not paragraph form- Highlight abnormal findings 

Assessment (the diagnosis) 

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each 
• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation 

Plan 

• Dx Plan (lab, x-ray) 
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) 
• Pt. Education, including specific medication teaching points 
• Referral/Follow-up 
• Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due 

Reference 

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.