Posted: May 1st, 2025

Problem focused soap note.

Scenario and template will be provided.

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