SOAP Notes

Subjective

Information from the patient or caregiver.

Subjective

Information is descriptive in nature and involves how the patient feels or what can be observed about the patient.

Subjective

Include subjective information pertinent to the problems being addressed.

Subjective

Chief Complaint (CC)

Subjective

History of Present Illness (HPI)

Subjective

Past Medical History (PMH)

Past Medical History (PMH)

List of serious illness, chronic illness, surgical procedures, and injuries previously experienced.

Subjective

Family History (FH)

Family History (FH)

Age and health of immediate family and relevant information for deceased family members

Subjective

Social History (SH)

Subjective

Home Medications: as provided by patient

Subjective

Allergies: List of allergens and the exposure outcome if known

Subjective

Review of Systems (ROS)

Review of Systems (ROS)

Examiner questions patient about the presence of symptoms that are relevant for each body system (head to toe)

Chief Complaint (CC)

Brief statement of the reason the patient contacted the healthcare provider; stated in the patient’s words.

History of Present Illness (HPI)

More complete description of patient’s symptoms

History of Present Illness (HPI)

Date of onset

History of Present Illness (HPI)

Precise location

History of Present Illness (HPI)

Nature of onset, severity, and duration

History of Present Illness (HPI)

Presence of exacerbations and remissions

History of Present Illness (HPI)

Effect of any treatment given

History of Present Illness (HPI)

Relationship to other symptoms, bodily functions, or activities

History of Present Illness (HPI)

Degree of significance to person’s activities

Social History (SH)

Social characteristics, environmental factors, and behaviors that may contribute to disease or treatment (e.g. tobacco use, alcohol use, occupational exposures, insurance status)

Objective

Data that can be measured or verified

Objective

Includes the history as reported in the medical record and the results of tests, procedures, and assessments.

Objective

Include objective information pertinent to the problems being addressed.

Objective

Vital Signs (VS)

Vital Signs (VS)

BP, RR, HR, Temperature, Ht, Wt, Pain level

Objective

Physical Exam (PE) (also called Physical Assessment)

Objective

Lab or diagnostic test results

Objective

Other confirmed data from the medical record (for example: medications administered in the hospital)

Assessment

Subjective and objective information are used while contemplating potential courses of action (for example: discontinue medication, change current medication, add medication, nonpharmacologic therapies)

Assessment

Each identified problem should be place in a prioritized list and assessed

Assessment

Etiology/Contributing factors: What caused the current problem

Assessment

Assessment if therapy is indicated: Statement of problem severity, acuity of problem, and the general therapeutic approach that is necessary.

Assessment

Goals of therapy: Appropriate goals for the patient and evaluation if the patient is currently at goal

Assessment

Assessment of current and/or new therapy

1. Clinician determines the best patient-specific therapy and provides rationale for therapy

2. Needs to include a statement that evaluates the SAFETY of the medication

3. Needs to include a statement that evaluates the EFFICACY of the medication with support from guidelines and/or primary literature

Assessment

Use 4H Method

• Have, Help, Harm, How – will be discussed in a future lecture

Plan

Succinct statements that encompass a comprehensive plan for each identified problem

Plan

Drug, dose, dosage form, route, schedule, titration (if applicable), and duration should be stated for all new medications and modifications of existing medication

Plan

Statements regarding problem-related medications that will be continued or discontinued should also be given

Plan

Therapeutic and toxicity monitoring parameters with timeline

Plan

Patient Education

Plan

Future Plans (for example: follow-up)