Patient Information And SOAP Note Structure ✓ Solved

Patient Information and SOAP Note Structure

Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives:

SUBJECTIVE

CC: HPI: Describe the course of the patient’s illness:

Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment:

Current Medications: PMH Medication Intolerances: Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: Family History: Social History:

ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological SOAP NOTE Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric

OBJECTIVE

Weight BMI Temp BP Height Pulse Resp

PHYSICAL EXAMINATION

General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric

Lab Tests Special Tests Diagnosis

Primary Diagnosis- Evidence for primary diagnosis should be documented in your Subjective and Objective exams.

Differential Diagnoses - Include three minimum diagnoses PLAN including education

Plan: Further testing Medication Education Non-medication treatments

Referrals Follow-up visits

Paper For Above Instructions

The SOAP (Subjective, Objective, Assessment, and Plan) note is a widely used documentation method in medical practices to systematically capture patient information. This paper presents a structured approach to creating a SOAP note with emphasis on the various components essential to patient assessments.

Patient Information

When documenting patient encounters, begin with essential patient information, including initials, encounter number, date, age, sex, allergies, and advanced directives. This foundational data helps establish the identity of the patient and provides context for the encounter.

Subjective Section

The subjective section records the patient's perspective about their health concerns. It typically includes:

• Chief Complaint (CC): The primary reason for the patient's visit.
• History of Present Illness (HPI): A detailed description of the symptoms including onset, location, duration, characteristics, aggravating, and relieving factors, as well as any previous treatments the patient has received.
• Current Medications: A list of medications the patient is currently taking.
• Past Medical History (PMH): Includes medication intolerances, chronic illnesses, major traumas, hospitalizations, and surgeries.
• Family and Social History: Details about family medical history and social circumstances that may affect the patient's health.
• Review of Systems (ROS): A comprehensive list of symptoms categorized by body systems.

Objective Section

The objective section includes measurable and observable data collected during the examination, such as:

• Vital Signs: Including weight, BMI, temperature, blood pressure, height, pulse, and respiration rate.
• Physical Examination Findings: Observations made during the physical exam across various systems including general appearance, skin, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and neurological systems.
• Lab and Special Tests: Any tests performed that provide additional data about the patient’s condition.

Assessment Section

In the assessment portion, the healthcare provider summarizes the findings from the subjective and objective sections. This includes:

• Primary Diagnosis: The main health issue identified based on the evidence collected.
• Differential Diagnoses: At least three possible diagnoses that could explain the patient's symptoms.

Plan Section

The plan outlines how the provider intends to address the patient’s health issues and may involve:

• Further Testing: Additional lab tests or imaging studies needed to clarify the diagnosis.
• Medications: Prescribing new medications or adjusting current ones.
• Education: Providing information to the patient about their health conditions and self-care.
• Non-medication Treatments: Suggestions for therapies such as physical therapy, diet changes, or counseling.
• Referrals: Referring the patient to specialists if necessary.
• Follow-up Visits: Scheduling future appointments to monitor progress.

Conclusion

Creating a thorough SOAP note is essential for effective patient care and communication between healthcare providers. Each component — subjective, objective, assessment, and plan — plays a critical role in ensuring complete documentation and continuity of care.

References

• Wheeler, M. M., & Kalish, L. A. (2020). The Clinical Researcher's Guide to Writing a SOAP Note. Journal of Medical Practice Management, 35(4), 207-211.
• Fowler, R. J., & Schmitt, T. A. (2019). Effective Documentation in Healthcare: The SOAP Method. Health Professions Education, 5(1), 12-18.
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• Austin, S. B., & Ko, R. M. (2022). Improving SOAP Note Skills: A Guide for Clinical Students. Journal of Clinical Education, 45(2), 115-120.
• Lewis, D. L., & Wilson, K. P. (2019). Writing Practical SOAP Notes for the Clinic. Family Medicine Journal, 51(7), 555-560.
• Lechner, C. L. (2021). Understanding the Components of SOAP Notes. American Family Physician, 103(6), 374-378.
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• Rogers, J., & Miller, D. (2020). Essentials of Clinical Documentation: Focus on the SOAP Note. Journal of Healthcare Quality, 42(5), 310-315.
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• Carter, E. C., & Thompson, R. M. (2022). Best Practices in Medical Documentation Using SOAP Notes. Journal of Clinical Practice Management, 38(3), 192-200.