CC: Ive been experiencing severe sharp menstrual pain and cramping just prior to and during the first two days of my menses.
Universal SOAP Note Template
Students Name:
Gender:
Comment:
Date:
Male
Age:
Date of Birth:
Ethnicity:
Female
SUBJECTIVE DATA
Chief
Complaint
(CC)
History of
Present
Illness (HPI)
**GYN
Focus**
In patients own words. Identity and reliability of informant if
patient is not informant.
Must include Onset, Location, Duration, Characteristics,
Aggravating factors, Relieving factors, Timing, and Severity
(OLDCARTS). Include pertinent positives from the review of
systems as they relate to the HPI.
OB/GYN
history
Gravida/Para. Last menstrual period. Last PAP w/ results. Last
Mammogram w/ results.
Sexual
History
History of STD, last sexual partner, sexual history, birth control
hx, sexual orientation,
Past Medical
History
(PMH)
In chronological order: Current/Past medical problems with date
of onset
Past Surgical
History
(PSH)
1
In chronological order: Surgeries and Procedures with date
performed and outcome
Immunizatio
n status
Age specific immunizations, list and describe any history of
reactions
Medications
**birth
control**
Current medications: include medication name, dose, route,
frequency, duration, and reason for taking
2
Allergies
Medications, Foods, Environmental, Latex and how allergy is
manifested
Family
History (FH)
Blood relatives: Age, living/deceased, medical problem. Include
grandparents, siblings, children
Social
History (SH)
(marital status, children), Lifestyle risk factors (illicit drug use,
smoking/pack year, exercise) , Employment history, Education,
Religion beliefs, Cultural history, Support System, Stressors,
Driving
Review of
Systems
(ROS)
In this section for each system you need to start the sentence by
saying either patient reports or patient denies
Constitution
al
General statement by the patient (reported symptoms that do not fit
one system but often affect overall status)
Skin
(example) patient denies rash, itching, or lesions
Or patient reports dry skin
Eyes, Ears,
Nose
Throat/Mout
h
Cardiovascu
lar
Respiratory
3
Gastrointesti
nal
Reproductiv
e / Genitalia
/
Genitourina
ry
Breast/Lymp
hatics
Musculoskel
etal
Neurological
OBJECTIVE DATA
Physical Exam
General/Constitutio
nal
General description of patient including age, gender,
nutritional status, habitus, attention to grooming, state of
cooperativeness/demeanor, overall picture of
wellness/distress
Vital Signs
Temperature, Pulses (apical and radial), Respirations, BP
(Ht, Wt, BMI)
Skin
HEENT
Neck
Respiratory
Cardiovascular
4
Breast/Lymphatics
Abdomen
Female
Genitourinary/
GYN
Rectal
Vulvar Exam:
Speculum Exam:
Cervical Exam:
Bi-manual Exam:
(Describe all assessment findings for each portion of the
GYN exam, if portion of exam was not one- please document
deferred)
Rectal Exam:
Musculoskeletal
Including frailty
evaluation if
applicable
Neurological
(Mental Status, Cranial nerves, Motor, Cerebellum, Motor,
Cerebellum, Sensory, Reflexes)
Diagnostic
Information
Results of diagnostic testing conducted at the time of the visit
OR previously done and being used to support the diagnosis
and management plan for the current visit
5
DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA
3 differential diagnoses
for each presenting problem
(Population specific wellness exam if
no problems identified)
Data in your assessment that supports
or rules out this diagnosis
Final ICD 10 diagnosis codes for the current visit
ICD 10 Code
1.
Corresponding Diagnosis
2.
3.
4.
5.
6
TREATMENT PLAN
(For graded SOAP note submissions, include rationale for all components of
treatment plan and support with citations from peer-reviewed information)
Additional
Diagnostic tests
needed
Treatments:
Pharmacological
Treatments:
NonPharmacological
Patient
Education
Consultations
recommended
with
Rationale
Return to
Clinic/FollowUp
Next office visit scheduled, identify the plan for follow-up, note
expectations for further treatment.
7
CPT Billing Codes Reflected in the Treatment Plan
CPT Code
Corresponding Diagnosis
1.
2.
3.
4.
5.
8
FNP Student
West Coast University
Patient Name _____________________________________ Date
___________________
Rx
Refill NR 1 2 3 4 5
Signature ____________________________________________________________
9
Discussion: (for Problem-focused SOAP notes ONLY)
Please provide a 1-2 paragraph discussion on your case. This can be why you
chose the specified/prescribed treatment plan, the pathophysiology of the
assessment, why you referred the patient for a specific diagnostic test, etc.
References: Please use at least three current (within 5 years) guidelines, articles,
or textbook. Please list.
10
