Soap Note

Create a Soap Note on a Sick Adult Patient

Identifying Data: Age, Gender, Occupation, and Marital Status

Source and Reliability:

S: Subjective:

Chief complaint or appropriate health screening visit:

The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – may be a brief summary of reason patient wanted to be seen for this visit. Typically, in quotations and is in patient’s own words (if able).

HPI:

Complete subjective description of problem, including “OLDCARTS” findings or similar, including location, quality severity, duration, timing, context, modifying factors, associated signs/symptoms, relieving and aggravating factors, related systems.

Medications, including OTC and Herbals Preparation

Past Medical History:

Allergies – medications, food, environmental or seasonal. What type of allergic reaction(s) do they have with exposure.
Childhood Illnesses – Chicken pox, Rheumatic fever, Rubella, Measles, and Mumps
Adult Illnesses
Injuries
Current and previous, when were they diagnosed or approximately how long have they been diagnosed
Surgeries
Hospitalizations
Obstetric/Gynecologic
Psychiatric
Health Maintenance
Immunization status – DPT, MMR, Influenza, Hepatitis, Polio, and Pneumovax
Dental Exams (frequency and treatment)
Last eye exam (include results)
SBE/Pap/GYN/mammogram (include results)
Testicular/rectal exam (include results)
Colonoscopy
DEXA scan
Any other maintenance the patient may have completed

Family History:

Include presence or absence of specific illnesses in family such as

hypertension, diabetes, or cancer

Personal and Social History:

Educational level
Personal interests
Lifestyle – exercise and diet
Older Adults – ADLs and iADLs

Review of Systems:

Pertinent positives and negatives in the differential diagnosis. May include 10+ body systems or can contain focused areas.

O: Objective:

Vital Signs

Blood Pressure
Temperature
Pulse
Respirations
Height
Weight
BMI including normal, overweight, obese, morbidly obese

Physical Examination

Specific systems as appropriate. As the ROS, may include all body systems or may contain focused areas.

Diagnostic Tests

This is the last component of the objective area. Should include any laboratory or other diagnostic tests. List name of test, then result(s).

Assessment/Plan

Differential Diagnosis and Plan