Problem Focused SOAP Note

Instructions: Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.

Use the format below for your SOAP note. 

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded. 

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