S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of use.
SH Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
FH Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.
HEALTH PROMOTION & MAINTENANCE Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.
ROS
(put N/A in sections not completed day of exam) Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
VITALS: HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
Age: LMP: PAIN:
PHYSICAL EXAM
(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE DIAGNOSIS 1.
2.
3.
VISIT CODES CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)
Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.
FOLLOW UP