Example: 47-year old female presenting with abdominal pain. soap note
This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:
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Onset: When did the CC begin?
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Location: Where is the CC located?
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Duration: How long has the CC been going on for?
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Characterization: How does the patient describe the CC?
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Alleviating and Aggravating factors: What makes the CC better? Worse?
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Radiation: Does the CC move or stay in one location?
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Temporal factor: Is the CC worse (or better) at a certain time of the day?
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Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?
It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than include excessive detail.
History
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Medical history: Pertinent current or past medical conditions
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Surgical history: Try to include the year of the surgery and surgeon if possible.
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Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient's family.
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Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.
Review of Systems (ROS)
This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.
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General: Weight loss, decreased appetite
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Gastrointestinal: Abdominal pain, hematochezia
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Musculoskeletal: Toe pain, decreased right shoulder range of motion
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often.
Objective
This section documents the objective data from the patient encounter. This includes:
A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.
Assessment
This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.
Problem
List the problem list in order of importance. A problem is often known as a diagnosis.
Differential Diagnosis
This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.
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Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Repeat for additional problems
Plan
This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:
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State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative
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Therapy needed (medications)
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Specialist referral(s) or consults
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Patient education, counseling
A comprehensive SOAP note has to take into account all subjective and objective information, and accurately assess it to create the patient-specific assessment and plan.
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