LAVC Nursing Penicillins Allergy & Defecation Difficulties SOAP Note

SOAP Note Template

HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient, Could be from patient, family member, paramedics) If patient unconscious cannot get info from them.

Pertinent past medical history.  If available.

Current medications (list with daily dosages).

Objective – The physical exam and laboratory data section

Vital signs including oxygen saturation when indicated.

Focuses physical exam.

All pertinent labs, x-rays, etc. completed at the visit.

Assessment/Problem List – Your assessment of the patient’s problems

Assessment: A one sentence description of the patient and major problem

Problem list: A numerical list of problems identified

All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.”

Look up ICD 10 codes for Dx.  This is a good link – https://www.icd10data.com/search?s=hypertension

Try not to overthink this aspect – as it becomes overwhelming very quickly.

Plan – Your plan for the patient based on the problems you’ve identified

Develop a diagnostic and treatment plan for each differential diagnosis.

Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc.

Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.).