L.T 56 year old male came to the clinic with Uncontrolled Hypertension. It’s a problem focused soap note. 3 differential diagnosis needed ,treatment and plan. References 5 years and less. Citations needed. Each differential diagnosis must be supported with words (as evidenced by why yes or why not this diagnosis) On assessment include just Cardio vascular ,pulmonary system and neuro or GI This is an example for soap note Student Name and clinical course: (If no title page): ______________________ ID: Clients Initials*:_______Age_____ Race__________Gender____________Date of Birth___________ Insurance _______________ Marital Status_____________ *It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian. Subjective: CC: Patients own words, a few words, a sentence or less. Example: cough and fever HPI: In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 . Asian female presents to the clinic alone with complaint of _____________. Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives. ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines. Constitutional: Eyes: Ears/Nose/Mouth/Throat: Cardiovascular: Pulmonary: Gastrointestinal: Genitourinary: Musculoskeletal: Integumentary & breast: Neurological: Psychiatric: Endocrine: Hematologic/Lymphatic: Allergic/Immunologic: Past Medical History: ? Medical problem list ? Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.) ? Surgeries: ? Hospitalizations: ? LMP, pregnancy status, menopause, etc. for women Allergies: Food, drug, environmental Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use Family History: Social History: -Sexual history and contraception/protection (as applies to the case) -Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use) Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care) Objective Vital Signs: HR BP Temp RR SpO2 Pain Height Weight BMI (be sure to include percentiles for peds) Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today Physical Exam (write out by system): Start with a general survey: Assessment (you will often have more than one diagnosis/problem, but do the differential on the main problem) Differentials (with a brief rationale for each): 1. 2. 3. Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies) Plan (4 pronged-plan for each problem on the problem list) Diagnostics: Treatment: Education Follow Up: List plan under each Diagnosis. Example 1: Hypertension (I10) A: Lisinopril/HCT 20/ Daily #90, refills 3 B: BMP in 6 months C: Recheck BP in 2 Weeks D: Low Sodium Diet and lifestyle modifications discussed 2: Morbid Obesity BMI () A: Goal of 5% weight reduction in 3 months B: Increase exercise by walking 30 minutes each day C: Portion Size Education 3: T2 Diabetes with diabetic neuropathy () A: Repeat A1C in 3 months B. Increase Metformin to 1000mg BID #180, refills: 3 C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X) D: Daily blood glucose check in the am and when sick E. Return to clinic in 3-4 months to reassess.
