ANSWER
Template for SOAP Notes with Patient Data
Name: [First initials]
Age: Subjective Date: Sex:
“[Patient’s main complaint in their own words]” is the Chief problem (CC).
History of Present Illness (HPI): [Explain the patient’s current condition in detail, including its onset, duration, location, features, aggravating and mitigating variables, related symptoms, and any treatments that have been tried.]
Past Medical History (PMH): [List prior hospital stays, surgeries, diseases, allergies, and long-term conditions.]
Medication: [List all of your current prescriptions, along with the frequency and dosage.]
Family History (FH): [Explain any pertinent medical history in your family.]
Social History (SH): [Include lifestyle aspects like food, exercise, living conditions, drug and alcohol use, and smoking.]
System Review (ROS):
General: [such as changes in weight, exhaustion, fever, etc.]
HEENT: [such as sore throats, headaches, or changes in vision]
Cardiovascular: [such as palpitations, chest pain, etc.]
Respiratory: [such as coughing, loss of breath, etc.]
GI: [such as diarrhoea, vomiting, nausea, etc.]
GU: [such as hematuria, dysuria, etc.]
MSK: [e.g., muscle aches, joint discomfort, etc.]
Neuro: [such as weakness, lightheadedness, etc.]
Psych: [such as anxiety, sadness, etc.]
Signs of Objective Vitality:
BP, HR, RR, Temp, SpO2, Physical Examination:
Overall Look: [such as healthy, distressed, etc.]
HEENT: [such as throat erythema, EOMs intact, PERRLA, etc.]
Cardiovascular: [e.g., murmurs, regular S1/S2]
Respiratory: [e.g., wheezing, bilateral clear auscultation, etc.]
[Soft, non-tender, etc.] Abdomen
Neurological: [e.g., no focal impairments, intact CN II-XII]
Other Systems That Are Relevant: [According to the patient’s complaint.]
Diagnostics/Imaging: [If available, provide any imaging, diagnostic tool, or lab test results that were carried out.]
Assessment Primary Diagnosis: [Give the most plausible diagnosis in light of the data supplied.]
Differential Diagnosis:
[A different diagnosis supported by evidence.]
[A different diagnosis supported by evidence.]
[A different diagnosis supported by evidence.]
Plan of Treatment:
[Name, dosage, and frequency of medication]
Non-pharmacological measures: [such as physical therapy, rest, etc.]
Diagnostics:
[Include any further imaging or testing required for confirmation.]
Patient Instruction:
[Give the patient an explanation of the diagnosis, available treatments, and prognosis.]
Follow-up:
[Indicate when follow-up visits should be scheduled or whether an early return is indicated.]
Suggestions:
[Send the patient to experts if required.]
Instructions for Submission
Make sure the SOAP note is formatted according to guidelines and is written in an understandable and succinct manner.
Avoid spelling and grammar errors.
When appropriate, back up your judgement and plan with evidence-based sources.
If you would like to add a specific patient scenario to this template, please let me know!
QUESTION
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
Click here to access and download the SOAP Note TemplateDownload Click here to access and download the SOAP Note Template
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.