S=Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS).
O=Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam(Focused), and Mental Status Exam.
A=Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes.
P=Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up.
SOAP NOTE BASED ON AN ENCOUNTER WITH A PATIENT WITH OPIOID DISORDER. LET’S MAKE HIM A MALE. 18 YRS OLD. HISPANIC. MAKE SURE WE USE THE TEMPLATE ATTACHED.
S=Subjective data: Patient’s Chief Complaint (CC); History of the Present Illnes
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