Problem-Focused SOAP Note Format
Demographic Data
Patient initial (one initial only), age, and gender must be HIPAA compliant.
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, iImmunizations, and preventative health maintenance
Family Hx
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
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Three (3) differential diagnosis (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.