Intro to SOAP Notes

SOAP

subjective

objective

assessment

plan

Subjective information

Chief complaint

introductory statement

HPI

Pertinent background

chief complaint

the primary symptoms x duration

introductory statement

FIRST SENTENCE OF HPI

patient name, age, ethnicity, gender, PMHx, chief complaint with duration

HPI

Chronology

Location

Setting

Quality

Quantity

alleviating or aggravating factors

associated manifestations

Setting

where was the patient at onset symptoms

what was the patient doing at the time

Chronology

the story of the chief complaint

how has it changed or developed over time

Location

where is the symptom on the body

ex) R vs L, deep or superficial

Quality

how they describe the symptom (english department)

Quantity

numerical value to the compliant (0-10) (math department)

Aggravating/Alleviating factors

what makes it better or worse

Associated Manifestations

Positive symptoms- what else they complain of

negative symptoms- symptoms associated with cc that the pt denies.

PMHx

injuries/illnesses/hospitalizations

Personal or Social history

- Tobacco, alcohol, illicit drug use

- Travel or occupational history

Family history

does it run in the family

ROS

Review of systems

ex) fever, chills, abdominal pain, nausea, vomiting

Allergies

include drug, latex, food, or environmental allergies

- Always include the reaction

ex) penicillin - hives

NKDA= No Known Drug Allergies

Medications

use the standard form

(Name, strength, dose, route, frequency, indication)

LNMP

Last normal menstrual period

make sure women aren't pregnant

Vital signs

temp, pulse, respiration, BP, height, weight, BMI, pulse ox

General Statements

- Age

- Habitus

- Race

- Gender

- Distress level

Problem Specific PE

Vital signs

general statement

HEENT

Neck

Chest/Lungs

Cardiac

Pulses

Abdominal

Genitalia

Rectal

MS

Neuro

Diagnostic Studies

- include a list of any studies and results that were reviewed with pt

- include any test that were completed at time of visits with results

ex) 9/28/26 rapid strep - negative

Primary Diagnosis

the acute diagnosis based off the patients symptoms and signs

- include appropriate R/O or DDx

- can be more than 1

- can be a symptom if not a diagnosis is not determined yet

examples of primary diagnosis

1. mild concussion R/O epidural hematoma

2. fracture of the left humerus

Secondary diagnosis

chronic medical conditions that have already been diagnosed

ex) hypotension- well controlled

tobacco use - uncontrolled

Plan

1. Diagnostic Tests

2. Pharmacological Treatment

3. Non-pharmacological treatment

4. Patient Education

5. Follow up

Diagnostic Tests

testing ordered at time of visit

list each on a separate line

ex) CMP

CBC

For specialized tests: need to indicate the reason for ordering

ex) CT scan without contrast STAT: R/O appendicitis

Pharmacological/Non treatment

medication prescribed for the Pt

OTC medication recommended for the pt

Any other recommendations for the patient

ex) honey, ice, humidifier

Patient Education

any additional information given to the pt

- include information regarding medication side effect

- symptoms or signs that warrant eval in ED

Follow up

when should the patient RTC or RTC prn