SOAP notes

Chief Complaint (CC)

symptoms or concerns causing patient to seek care

History of Present Illness (HPI)

contains identifying data

amplifies CC to describe symptoms development,location,timing

Past Medical History (PMH)

diagnoses date or length in childhood and adult illnesses

Past Surgical History (PSH)

past surgical procedures with dates,indications,operations

Family History (FH)

age and health of immediate relatives including presence or absence of key illnesses

Social History (SH)

alcohol,tobacco,and illicit drug use with quantity and frequency

describe family/home dynamics, lifestyle, education, job history, financial situation, retirement status, spiritual beliefs, ability to care for oneself

Allergies

medication and food with specific reaction

Current Medications

includes OTC drugs, vitamins, herbal or nutritional supplements

patient compliance and how they take it

Medications Prior to Admission (PTA)

for hospitalized patient’s as the medications may change inpatient vs outpatient

Review of symptoms (ROS)

question the patient pertaining to symptoms from head to toe

Laboratory Results

basic or complete metabolic, blood count, fasting lipid panels

thyroid and liver function tests

Test Results

X-ray, MRI, CT, U/S, angiograph and other radiographic evidence tests/procedures

bacterial cultures and sensitivities

Subjective data

patient’s description of problems told by patient or family

PMH and other histories included unless already documented in chart

Objective Data

physical examination findings and laboratory tests

Assessment

analysis and interpretation of data and patient health status

includes explaining the logic behind selecting the best plan from start to finish

show the pros and cons of treatment options for other HCP based on standards of practice

Pertinent Positives

presence of patient’s key signs and symptoms

Pertinent Negatives

absences of key signs and symptoms

Plan

accounts for pharmacotherapy changes and further tests to be ordered

includes follow-up/monitoring parameters and patient education for their safety