Comprehensive SOAP Template

This template is for a full history and physical. For this course include only areas that are related to the case.

Patient Initials: _______                 Age: _______                                   Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

L =location

O= onset

C= character

A= associated signs and symptoms

T= timing

E= exacerbating/relieving factors

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

Neck:

            Breasts:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Psychiatric:

            Neurological:

            Skin: 

Hematologic:

            Endocrine:

            Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.

ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

PLAN: Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition/follow up instructions as they pertain to your patients’ assessment. 

Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: Document what you learned from this experience? Any ah-ha’s?

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

________________________

Preceptor Signature and Date

Signature is REQUIRED for this assignment.