SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with vaginal discharge, you would examine the General appearance, Heart and Lungs, abdomen and pelvis for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term âRule Outâ¦â cannot be used as a diagnosis.
Subjective Data (20 pts.)
Chief Complaint (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP)
Allergies:
Past Medical History:
Family History:
Surgery History:
Obstetrical/GYN History:
Social History (alcohol, drug, or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI)
Objective Data (25 pts.)
Please remember to include an assessment of all relevant systems based on the CC and HPI.
Vital Signs/ Height/Weight:
General Appearance:
Assessment (20 pts.)
A: Differential Diagnosis
Please rule out all differential diagnosis with subjective and objective data and/or lab-work. Provide references.
1.
2.
3.
B: Medical Diagnosis
Rule in diagnosis with subjective and objective data and lab-work. Please explain how you arrived at the diagnosis. Provide references.
1.
PLAN (25 pts.)
A: Orders
1.Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided
2.Diagnostic testing needed
3.Problem oriented education
4.Interpersonal/Social support/communication
5.Age appropriate Health Promotion/Maintenance/Screening Needs
6.Referrals and follow up with rationales
Cultural Diversity: What cultural considerations would you suggest for this patient?
Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit.
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic) with rationales
APA Format (10 pts.)
Include a title page and references with all of your papers. There should be at least four references from textbooks, journal articles, CDC or NIH that are not older than 5 years. Please do not use Wikipedia, WebMD, dictionaries, or any websites that are not evidence based.
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