Problem-focused SOAP Note Format    

Problem-focused SOAP Note Format    

Demographic Data

Age, and gender (must be HIPAA compliant)

Subjective

Chief Complaint (CC): A short statement about why they are there

History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

Family Hx: any history of CA, DM, HTN, MI, CVA?

Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan

Dx Plan (lab, x-ray)

Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

Pt. Education, including specific medication teaching points

Referral/Follow-up

Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Reference

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

**Problem-focused SOAP Note**

 

**Demographic Data:**

– Age: 35

– Gender: Female

 

**Subjective:**

– **Chief Complaint (CC):** The patient presents with a complaint of persistent headache.

– **History of Present Illness (HPI):** Ms. Smith is a 35-year-old female who presents with a chief complaint of headache. The headache began abruptly two days ago and is located on the left side of her head, described as a throbbing sensation. She rates the pain intensity as 7/10 on a numeric rating scale. The headache is aggravated by bright lights and alleviated with rest and over-the-counter pain medications. She denies any recent head trauma or changes in vision. Ms. Smith reports no previous history of similar headaches. She has tried acetaminophen without relief.

 

– **Past Medical History (PMH):**

– No significant past medical or surgical history.

– Medications: Occasional use of acetaminophen for headaches.

– Allergies: None reported.

– Immunizations: Up to date.

– Preventative Health Maintenance: Last eye and dental exam six months ago. Pap smear and vaccines up to date.

 

– **Family History:**

– No family history of cancer, diabetes mellitus, hypertension, myocardial infarction, or cerebrovascular accident.

 

– **Social History:**

– Nutrition: Balanced diet, no specific dietary restrictions.

– Exercise: Regular exercise routine, jogging three times per week.

– Substance Use: Non-smoker, occasional alcohol use (socially).

– Occupation: Office manager, moderate stress level.

 

– **Review of Systems (ROS):**

– Constitutional: No fever or chills.

– Eyes: No changes in vision.

– Ears, Nose, Throat: No congestion or ear pain.

– Cardiovascular: No chest pain or palpitations.

– Respiratory: No cough or shortness of breath.

– Gastrointestinal: No nausea, vomiting, or diarrhea.

– Genitourinary: No urinary symptoms.

– Musculoskeletal: No joint pain or swelling.

– Neurological: Headache as described above.

– Psychiatric: No anxiety or depression symptoms.

 

**Objective:**

– **Vital Signs:**

– Blood Pressure: 120/80 mmHg

– Heart Rate: 72 bpm

– Respiratory Rate: 16 breaths/min

– Temperature: 98.6°F

– **Physical Examination:**

– Head: Tenderness noted on palpation of the left temporal area. No signs of trauma or swelling.

– Neurological: Cranial nerves II-XII intact. No focal neurological deficits noted.

 

**Assessment:**

– **Primary Diagnosis:** Tension-type headache.

– **Differential Diagnoses:**

Migraine headache: Ruled out due to absence of aura or nausea/vomiting.
Sinusitis: Less likely given the absence of nasal congestion or facial pain.

– **Final Diagnosis:** Tension-type headache, based on characteristic history and physical examination findings.

 

**Plan:**

– **Diagnostic Plan:** No further diagnostic testing indicated at this time.

– **Treatment Plan:**

– Medications: Acetaminophen 1000 mg PO every 6 hours as needed for headache.

– Patient Education: Advise the patient to maintain a headache diary and identify triggers. Encourage stress management techniques and regular sleep patterns.

– **Referral/Follow-up:** Follow-up appointment in two weeks for reassessment. No referral needed at this time.

– **Health Maintenance:** Schedule annual eye and dental exams. Discuss the importance of regular exercise and healthy diet.

 

**Reference:**

– American Headache Society. (2013). The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache: The Journal of Head and Face Pain, 53(2), 231–240. https://doi.org/10.1111/head.12046

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