Problem-focused SOAP Note Format
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
- Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
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
- Vital Signs
- Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
- Assessment (the diagnosis)
- At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
- Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
- Plan
Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
- Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
- Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
**Problem-focused SOAP Note**
**Demographic Data:**
– Age: 35
– Gender: Female
**Subjective:**
– **Chief Complaint (CC):** The patient presents with a complaint of persistent headache.
– **History of Present Illness (HPI):** Ms. Smith is a 35-year-old female who presents with a chief complaint of headache. The headache began abruptly two days ago and is located on the left side of her head, described as a throbbing sensation. She rates the pain intensity as 7/10 on a numeric rating scale. The headache is aggravated by bright lights and alleviated with rest and over-the-counter pain medications. She denies any recent head trauma or changes in vision. Ms. Smith reports no previous history of similar headaches. She has tried acetaminophen without relief.
– **Past Medical History (PMH):**
– No significant past medical or surgical history.
– Medications: Occasional use of acetaminophen for headaches.
– Allergies: None reported.
– Immunizations: Up to date.
– Preventative Health Maintenance: Last eye and dental exam six months ago. Pap smear and vaccines up to date.
– **Family History:**
– No family history of cancer, diabetes mellitus, hypertension, myocardial infarction, or cerebrovascular accident.
– **Social History:**
– Nutrition: Balanced diet, no specific dietary restrictions.
– Exercise: Regular exercise routine, jogging three times per week.
– Substance Use: Non-smoker, occasional alcohol use (socially).
– Occupation: Office manager, moderate stress level.
– **Review of Systems (ROS):**
– Constitutional: No fever or chills.
– Eyes: No changes in vision.
– Ears, Nose, Throat: No congestion or ear pain.
– Cardiovascular: No chest pain or palpitations.
– Respiratory: No cough or shortness of breath.
– Gastrointestinal: No nausea, vomiting, or diarrhea.
– Genitourinary: No urinary symptoms.
– Musculoskeletal: No joint pain or swelling.
– Neurological: Headache as described above.
– Psychiatric: No anxiety or depression symptoms.
**Objective:**
– **Vital Signs:**
– Blood Pressure: 120/80 mmHg
– Heart Rate: 72 bpm
– Respiratory Rate: 16 breaths/min
– Temperature: 98.6°F
– **Physical Examination:**
– Head: Tenderness noted on palpation of the left temporal area. No signs of trauma or swelling.
– Neurological: Cranial nerves II-XII intact. No focal neurological deficits noted.
**Assessment:**
– **Primary Diagnosis:** Tension-type headache.
– **Differential Diagnoses:**
- Migraine headache: Ruled out due to absence of aura or nausea/vomiting.
- Sinusitis: Less likely given the absence of nasal congestion or facial pain.
– **Final Diagnosis:** Tension-type headache, based on characteristic history and physical examination findings.
**Plan:**
– **Diagnostic Plan:** No further diagnostic testing indicated at this time.
– **Treatment Plan:**
– Medications: Acetaminophen 1000 mg PO every 6 hours as needed for headache.
– Patient Education: Advise the patient to maintain a headache diary and identify triggers. Encourage stress management techniques and regular sleep patterns.
– **Referral/Follow-up:** Follow-up appointment in two weeks for reassessment. No referral needed at this time.
– **Health Maintenance:** Schedule annual eye and dental exams. Discuss the importance of regular exercise and healthy diet.
**Reference:**
– American Headache Society. (2013). The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache: The Journal of Head and Face Pain, 53(2), 231–240. https://doi.org/10.1111/head.12046
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