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
SUBJECTIVE:
HPI
PMHx
FHx
SHx
Medications
ROS
OBJECTIVE:
Vitals with BMI
Constitutional
HEENT
Cardiac
Pulmo
GI
Musculoskeletal
Skin
GU – if relevant
Always provide a very detailed physical exam, or description of what you want
to elicit on your physical exam on the organ system involved in your chief
complaint
ASSESSMENT:
Working Diagnosis
– provide ICD 10 codes
– provide rationales or pertinent positives and negatives that made you consider the
diagnosis
Differential # 1
– diagnosis you cannot miss.
– rationale why it can’t be missed
– provide ICD 10 code
Differential # 2
– what else could it be?
– rationale why you ruled it out
-provide ICD 10 Code
PLAN
Diagnostics
Pharmacological Plan – indicate dosage and regimen, if not indicated state
accordingly
Health Education Plan
Referral Plan – if not indicated, state accordingly
Follow-up plan – indicate when patient needs to follow-up and what symptoms
to watch out for
Health promotion plan – age-specific health promotion recommendations not
related to the case per USPTF
REFERENCES
SAMPLE OF PROBLEM FOCUSED SOAP
Demographic Data
1. 29 year old/Female
Subjective
Chief Complaint (CC): Left sided chest tenderness
History of Present Illness (HPI): B. is a 29-year-old Caucasian male presenting to clinic for
follow-up of pericarditis, and annual well exam. Patient states that chest is still tender s/p
bicuspid aortic valve replacement 08/01/2018, however symptoms of chest pain, back
pain, shortness of breath, and dyspnea are not present. Pt. describes the pain as localized
dull and aching similar to tenderness post-operatively. Patient is aware that contact needs
to be made with cardiologist if cardiac symptoms return. Pt. c/o left sided chest
tenderness and was diagnosed with pericarditis by cardiologist. Pt. was given steroids by
cardiologist and admits to complying with medication and has shown improvement in
chest pain. Pt. denies aggravating factors, other than palpation.
Past Med. Hx (PMH): Congenital bicuspid valve (CBV). CBV is considered the most
common cause of aortic stenosis in young individuals. In this birth defect, only two cusps
grow instead of the usual three. Stenosis can also occur in the young when the valve
opening does not grow along with the heart, which makes the heart work harder to pump
blood to the restricted opening and throughout the years, the defective valve stiffens and
narrows because of calcium build up (American Heart Association, 2018). Pt. had a
bicuspid valve replacement on 08/01/2018. No other hospitalizations, surgeries, medical
or surgical problems. Pt. up to date on all childhood vaccinations, will be receiving annual
flu vaccine today in office. No known allergies.
Family Hx: Pts mother has hypercholesterolemia. No other family history available.
Social Hx: Pt. states his diet is well balanced, incorporating foods from all food groups. Pt.
states currently he is afraid to exercise too hard after the gym but states he will start
walking nightly very soon. Pts occupation as a video editor requires him to sit down
throughout the day and have high stress deadlines. Denies substance use, tobacco, and
alcohol. Pt. lives with and is currently only sexually active with his girlfriend of nine years.
Review of Systems (ROS):
General: Pt denies fever, chills, and night sweats. Pt. admits to intentional
weight gain in the past year.
Cardiac: Pt. denies chest pain, SOB or any cardiac events. Pt. admits to a 3/10
chest tenderness on left anterior chest upon palpation s/p bicuspid valve
replacement on 08/01/2018. Pts cardiologist informed, and pericarditis dx.
given along with steroid therapy, with positive outcomes.
Respiratory: Pt. denies SOB, wheezing, & difficulty breathing.
Gastrointestinal: Pt. denies N/V, diarrhea, and constipation. No blood in stool.
Musculoskeletal: Pt. denies body aches, difficulty in performing daily tasks,
though admits to fear of exercising too soon after surgery. Pt. c/o chest
tenderness s/p surgery, but denies radiation to any other muscle groups or
back.
Psychosocial: Pt denies suicidal ideation/homicidal ideation, auditory/visual
hallucinations. Pt denies feeling depressed or anxious. Mother and girlfriend
actively involved in patients life for positive support system.
Objective
Height: 5ft. 9inchs Weight: 145lbs BMI: 21.4 (normal BMI)
Vitals
Blood Pressure: 109/82
Heart Rate: 70
Respirations: 18
Pulse Ox: 99% ORA
Temperature: 98.8F oral
ROS:
General: Pt appears calm and pleasant. Behavior, mood, and affect appropriate.
Cardiac: Heart rate and rhythm regular. Pulses equal and even bilaterally upper
and lower extremities 2+. S1 & S2 heard. No murmurs, gallops, or pericardial
friction rub. Surgery wound closed, and healed, no draining, pus, or
abnormalities seen. No edema in extremities.
Respiratory: Lung sounds clear to auscultation on all basis, anteriorly and
posteriorly. No dyspnea. No distress.
GI: Bowel sounds present in all four quadrants. No rebound tenderness. No
mass lumps or bumps noted. Abdomen is round. Umbilicus midline. No
organomegaly. (-) CVA tenderness.
Musculoskeletal: Full ROM of upper and lower extremities. Gait steady.
Assessment
Working diagnosis:
Acute Pericarditis (AP) AP is the most common pericardial syndrome. There
are multiple causes of AP and can be classified as either infectious and noninfectious. It has a multifactorial etiology and depends on the epidemiological
background, patient population and clinical setting. In developed countries, the
most common cause of pericarditis is viruses, and tuberculosis in developing
countries. The diagnosis of AP is clinical and can be made either on the
presence of pericardial chest pain in the patients medical history, pericardial
rubs upon auscultation, new widespread ST-elevation or PR depression on
ECG, or new or worsening pericardial effusion. Diagnostic CT and MRI will also
provide accurate findings of large pericardial effusion. Typical presentation is
chest pain radiating to the trapezius ridge, left shoulder, or arm and mimicking
ischemic pain. The retrosternal pain in AP is primarily sharp and pleuritic,
worsened by supine position, coughing, and upon deep inspiration. The pain is
subsided by learning forward and an upright position due to the decrease of
pressure on the parietal pericardium. Common signs of AP include low-grade
intermittent fever, dyspnea, cough, malaise, myalgia and sometimes
unrelenting hiccups. Auscultation will also expose pericardial friction rub due to
increased friction of inflamed pericardial layers (Xanthopoulos & Skoularigis,
2017). These mentioned signs all serve as pertinent negatives for diagnosis of
chronic pericarditis. Since patient is currently on anti-inflammatory steroid
therapy, symptoms are well managed.
Differential diagnosis:
Unspecified angina pectoris: This form of chest pain comes from coronary heart
disease, usually when the heart does not get as much blood as it needs, as is the
case in ischemic conditions. Angina causes uncomfortable pressures, tightness,
feeling of fullness, squeezing, and pain which may or may now radiate to the
neck, jaw, shoulder, back or arm (Angina pectoris- stable angina, 2018).
Cardiac tamponade: This clinical syndrome is caused by the accumulation of
fluid in the pericardial space, which results in reduced ventricular filling and
subsequent hemodynamic compromise (Cardiac tamponade, 2018). Pertinent
negatives include breathing problems, fainting, lightheadedness, palpitations,
edema, jaundice, weakness, dizziness, drowsiness, or absent pulses.
Surgical wound infection: Any time an incision is involved, it can lead to a
wound infection after surgery. Most infections show up within the first 30 days
after surgery by bacteria that is already present on the skin, and proceeds to
spread to the surgical wound, bacteria in the air, bacteria inside the body, poor
hand hygiene of staff, and even infected surgical instruments (Surgical wound
infection, 2018).
Plan
Dx Plan: A medical history and physical exam are main components of the diagnostic
criteria. Laboratory testing to include WBC, ESR, CRP, troponin, CBC, urea, creatinine. An
ECG, transthoracic echocardiography, and chest x-ray can also help in diagnosis. This
patient has already been through the above-mentioned tests through cardiologists office
and is receiving ongoing treatment through medication therapy.
Tx Plan (meds): Continuation of medications prescribed by cardiologist.
Indomethacin 25mg, PO, BID.
Prednisone 30mg, PO, once daily
Colchicine 0.6mg, PO, BID
Pt. Education: Pt. to continue anti-inflammatory therapy as prescribed by cardiologist
until discontinued by cardiologist. Medications to be taken with food, and not abruptly
stopped. Pt. to continue to follow normal diet and exercise as tolerated.
Referral/Follow-up: Follow up with cardiologist, as requested by cardiology office.
Health maintenance: Pt. will be getting flu vaccine in office visit, and Tdap was given to pt.
in hospital on 08/2018. Pt. advised to increase exercise to improve blood flow and heart
health (American Heart Association, 2018). USPT health promotion recommendations
include screening for depression, anxiety, STIs, cervical cancer, substance abuse/ smoking,
etc.
National Standards of Care:
Patients with acute pericarditis with one or more high-risk features (including fever,
subacute course, suspected cardiac tamponade, immunosuppression, acute trauma,
treatment with oral anticoagulation, or elevated cardiac troponin) are at increased risk for
complications and should generally be admitted to initiate appropriate therapy and to
expedite a thorough initial evaluation. Conversely, patients with uncomplicated (ie, lowrisk) acute pericarditis can usually be evaluated and sent home, with outpatient follow-up.
References
Angina pectoris- stable angina. (2018). American Heart Association. Retrieved from
http://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/angina-pectorisstable-angina
Aortic Valve Stenosis. (2018). American Heart Association. Retrieved from
http://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valveproblems-and-causes/problem-aortic-valve-stenosis
Cardiac tamponade. (2018). United States National Library of Medicine. Retrieved from
https://medlineplus.gov/ency/article/000194.htm
Surgical wound infection. (2018). United States National Library of Medicine. Retrieved
from
https://medlineplus.gov/ency/article/007645.htm
Xanthopoulos, A., & Skoularigis, J. (2017). Diagnosis of acute pericarditis. Retrieved from
https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume15/Diagnosis-of-acute-pericarditis
