Case Study 8

SOAP NOTE TEMPLATE

Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.

Subjective Data

Chief Complain (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP- if applicable)

Allergies:

Past Medical History:

Family History:

Surgery History:

Social History (alcohol, drug or tobacco use):

Current medications:

Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)

Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

Assessment

A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work.  

1.

2.

3.

B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.

 

1.

PLAN

A: Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

2. Diagnostic testing

3. Problem oriented education

4. Health Promotion/Maintenance Needs

5. Referrals

B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)