Problem Focused SOAP Note

Posted: February 15th, 2023

Problem Focused SOAP Note
WCU Adult Gero SOAP Note Template
Use this template for Comprehensive Notes (Initial Comprehensive/Annual visit) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes, only include pertinent problem-focused information related to the chief concern (CC).

Demographic Data
o Patient age and gender identity
o MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
O Place the complaint in Quotes
O Brief description -only a few words and in the patient’s words
O Example: “My chest hurts,” “I cannot breath,” or “I passed out,” etc.
History of Present Illness (HPI) – the reason for the appointment today
O Use the OLDCARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity
O Briefly describe the general state of health prior to the problem.

PAST MEDICAL HISTORY:
O List current and past medical diagnoses (in list format)

PAST SURGICAL HISTORY:
O List all past surgeries including dates (in list format)

FAMILY HISTORY:
O Include medical/psychiatric problems to include 2 generations (parents, grandparents, siblings, or direct relatives (in list format).

CURRENT MEDICATIONS:
O Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.
O Include Name of medication, Dosage, Route, frequency.

ALLERGIES:
O Include medications, foods, and chemicals such as latex.
O Include reaction type in parenthesis.
O Example: Penicillin (Hives)

IMMUNIZATIONS HISTORY: list current immunization status and address deficiency

HEALTH MAINTENANCE: (See Table below – Appendix A)
o List any age appropriate health maintenance due/recommended in list format.
SOCIAL HISTORY:
O An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs/Alcohol; Sexuality.
O Employment/Education should include: occupation (type), exposure to harmful agents, highest school achievement

REVIEW OF SYSTEMS:
O A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.
O Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.
O Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).
O Pertinent positives should be documented first.
O Do not repeat the information provided in HPI
O Documented as “Reports” or “Denies”

Example of an exemplary negative ROS for a Comprehensive Note.
General: Denies malaise, weakness, fever, or chills. Denies recent weight gains or losses of >20 pounds over the last 6 months.

Eyes: Denies change in vision or loss of vision, eye pain, sensitivity, or discharge.
Ears, nose, mouth & throat: Denies ear pain, loss of or decreased hearing, ringing of the ears, drainage from the ears. Denies change in sense of smell, nose bleeds, sinus or facial pain, speaking problems, hoarseness or choking, dry mouth, dental problems, or difficulty chewing or swallowing.

Cardiovascular: Denies chest discomfort, heaviness, or tightness. Denies abnormal heartbeat or palpitations. Denies shortness of breath, denies having to sleep elevated on 2 pillows or more, no swelling of the feet, no passing out or nearly passing out. Denies history of heart attack or heart failure.

Respiratory: Denies cough, phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home, no known exposure to TB or travel outside the country. Denies history of asthma, COPD/emphysema or any other chronic pulmonary disease.

Gastrointestinal: Denies nausea, vomiting, abdominal discomfort/pain. Denies diarrhea, constipation, blood in the stool or black stools. Denies hemorrhoids, trouble swallowing, heartburn or food intolerance. Denies history of liver or gallbladder disease. No recent weight gains or losses of > 20 pounds within the last year.

Skin & Breasts: Denies rash, itching, abnormal skin, or recent injury. Denies breast pain, discharge, or other abnormality was reported by the patient.

Musculoskeletal: Denies muscle or joint pain, back or neck pain, and denies recent accidents or injuries. Denies physical disability or condition that limits activity or ADLs.

Allergic: Denies history of seasonal allergies, allergic rhinitis, watery eyes, or wheezing. Denies history of HIV, hepatitis, shingles, or recurrent infections

Immunologic: Denies history of HIV, TB, hepatitis, shingles, or other recurrent infectious diseases. Denies history of cancer – radiation or chemotherapy.

Endocrine: Denies polyuria, polydipsia, and polyphagia. Denies history of blood sugar instability. Denies temperature intolerance to hot or cold. Denies swelling of the neck or nodules.

Hematopoietic/Lymphatic: Denies unusual lumps or masses. Denies bruising quickly or bleeding easily. Denies history of anemia or recent blood transfusions. Denies sickle cell disease or trait. Denies blood dyscrasias.

Genitourinary: Denies dysuria, frequency, or urgency. Denies abnormal vaginal/penile discharge or bleeding. Denies recent history of bladder or kidney infections/stones. Denies sexual dysfunction or concerns.

Neurological: Denies unusual headaches, history of head injury or loss of consciousness, lightheadedness, dizziness, vertigo. Denies numbness of a body part or weakness on one side of the body. Denies pins and needle sensation, abnormal movements, or seizure disorder. Denies previous strokes, seizures or neurological disorders.

Psychiatric/Mental Status: Denies history of depression or anxiety. Denies difficulty sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations. Denies history of psychosis or schizophrenia. Denies difficulty concentrating or change in memory.

Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate. Respirations. SaO2 (on room air or O2). Temperature. Weight. Height. BMI.

Example of exemplar PE for a Comprehensive Note with no abnormal findings.
CONSTITUTIONAL/GENERAL APPEARANCE: Vital signs stable, in no acute distress. Alert, well developed, well nourished.

HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae were white. Conjunctivae and lashes were clear. No lid lag. Extraocular movements were intact (EOMI). PERRLA.
ENT: Ears, nose, mouth, and throat: Mucous membranes were pink, moist and intact. External ear canals were clear without cerumen. TMs were clear, pearly gray with good light reflex bilaterally. Hearing was intact to whisper. Nares patent and mucosa is pink, moist and intact. Mouth, lips and tongue, gums were intact with no lesions. Good dentition. Hard and soft palates intact. Tongue and uvula midline.

NECK: Supple. No JVD, thyromegaly or lymphadenopathy.

RESPIRATORY/CHEST: Unlabored. Chest rise is equal and symmetric. Lungs are CTA bilaterally with no adventitious breath sounds.

CARDIOVASCULAR: S1, S2 without murmurs, rubs or gallops appreciated.

BREASTS: Skin intact without lesions, masses, or rashes. No nipple discharge. Breasts with slight asymmetry, no dimpling, retractions or peau d’orange appearance.

GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No tenderness, masses, or hernias appreciated.

GENITAL/RECTAL: no suprapubic tenderness or bladder bulges. No lesions, rashes, masses or swelling.

LYMPH NODES: No enlarged glands of the neck, axilla or groin.

MUSCULOSKELETAL: Gait and station were within normal limits. Full range of motion in all joints. Muscle strength and tone were 5/5 all groups. Equal arm swing.

INTEGUMENTARY: Skin was warm and intact. No rashes, lesions, masses or discoloration. No abnormalities to fingers or toenails noted.

EXTREMITIES: No cyanosis or clubbing. No edema of the extremities. Pulses +2 bilaterally radial and pedal.

NEURO: Cranial nerves are intact grossly, II-XII. DTRs intact, +2 bilaterally with symmetric response. Sensation intact to light touch. No motor or sensory deficits.

PSYCH: A&O x3. Recent and remote memory intact. Mood and affect appropriate during visit. Judgment and insight were within normal limits at the time of visit.
*Full mini-mental status exam may be indicated based on the CC or findings in the ROS or physical exam.
Assessment (Diagnosis)
Differential Diagnosis (DDx)
O Include two (2) differential diagnoses you considered but did not select as the final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential with an evidence-based guideline(s) (required).

Working or Final Diagnosis:
O Final or working diagnosis (1) (including ICD-10 code)
O Provide a rational explanation supported by evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
O Diagnostics. Any labs, imaging, ordered? Remember you are managing this patient in the outpatient/clinic setting, not the hospital.
O Pharmacologic -include full prescribing information for each medication(s) ordered. Name of Medication, Dosage, Route, Frequency, Duration, number of tabs prescribed, number of refills.

Patient Education:
O include specific education related to each medication prescribed.
O Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan?
O NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use, was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?

Referral/Follow-up
O When would you like the patient to be seen in clinic again. Did you recommend follow-up with PCP, or other healthcare professionals/specialists?
O When is the subsequent follow-up?
Reference(s)
o Include APA formatted references for written assignments.
o Minimum 2 references are required from evidence-based resources.

APPENDIX A

Health Maintenance (Example – not all-inclusive)

Preventive Care
Pap
Mammogram
A1C
Eye Exam
Monofilament Test
Urine
Microalbumin
Diet/Lifestyle Changes
Digital Rectal Exam (DRE)
PSA
Colonoscopy or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
The Prevention TaskForce (formerly ePSS) application assists primary care clinicians to identify the screening, counseling, and preventive medication services that are appropriate for their patients.

Download this app and be sure to reference when assessing Health Maintenance priorities for your patients:

https://www.uspreventiveservicestaskforce.org/apps/

Use template and make up the rest

Chief Complaint – “My muscles ache and my throat hurts alot. Ive also had a fever of 100.6 since yesterday”

S: CC: Parent is concerned about possible strep throat in their 13-year-old child. Child presents with sore throat for 2 days.
O: General appearance is well but uncomfortable. T: 101.0 F. Oral exam reveals erythematous throat with enlarged tonsils with exudate. No cervical lymphadenopathy. Lungs CTA. Heart RRR. Abdomen soft, NTND. Extremities WNL.
A: Sore throat. Suspected strep throat.
P: Educate parent on signs of worsening infection such as high fever, severe throat pain, inability to swallow or drink. Advise over-the-counter pain relievers as needed and adequate fluid intake. Prescribe a 10-day course of penicillin or alternative antibiotic if allergic. Instruct to finish full course of antibiotics and return if no improvement in 48 hours or earlier with worsening symptoms. Provide handouts on strep throat and when to seek medical attention. Schedule follow-up call in 5-7 days to assess response to treatment.

SOAP Note Format:

Subjective: This section includes the patient’s chief complaint (CC), history of present illness (HPI), past medical history, etc., all gathered through the patient’s own words and perspective.
Objective: This section presents the clinician’s findings obtained through physical examination, tests, and other measurements.
Assessment: This section combines the subjective and objective data to arrive at a diagnosis or differential diagnoses.
Plan: This section outlines the treatment plan, including medications, education, referrals, and follow-up instructions.

Important Notes:

Always adhere to HIPAA regulations and avoid including any identifying patient information.
Use clear and concise language, avoiding medical jargon when possible.
Support your assessments and plan with evidence-based guidelines and rationale.
Tailor the SOAP note template to fit the specific needs of your practice and patient population.

Diagnosis – COVID

Differential – Strepthroat , Flu