SOAP NOTE FORMAT please. No cover page or page numbers. Use topic as heading. example and patient information are in attachments!!!! Use current APA format to style your paper and to cite your sources.
PATIENT INFORMATION IS BELOW IN ATTACHMENTS
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.
SUBJECT- Symptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, relevant with no extraneous data.
OBJECT- Complete, concise, well organized and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.
DDX-Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data.
PLAN- Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).
