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Soapwhat To Write

The SOAP note format template outlines sections for subjective information, objective examination findings, assessment of problems, and treatment plan. The subjective section includes the patient's history, review of systems, and current medications. The objective section lists vital signs, physical exam findings, and laboratory results. The assessment identifies the main problem and differential diagnoses supported by the subjective and objective findings. Finally, the plan outlines diagnostic and treatment steps for each diagnosis, including education, medications, follow-up care.

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Joriza Tamayo
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251 views1 page

Soapwhat To Write

The SOAP note format template outlines sections for subjective information, objective examination findings, assessment of problems, and treatment plan. The subjective section includes the patient's history, review of systems, and current medications. The objective section lists vital signs, physical exam findings, and laboratory results. The assessment identifies the main problem and differential diagnoses supported by the subjective and objective findings. Finally, the plan outlines diagnostic and treatment steps for each diagnosis, including education, medications, follow-up care.

Uploaded by

Joriza Tamayo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Template for Clinical SOAP Note Format

Subjective The history section


HPI: include symptom dimensions, chronological narrative of patients complains,
information obtained from other sources (always identify source if not the patient).
Pertinent past medical history.
Pertinent review of systems, for example, Patient has not had any stiffness or loss
of motion of other joints.
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 patients 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.
Provide at least 2 differential diagnoses for the major new problem identified in your
note.
Plan Your plan for the patient based on the problems youve 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.).
Also see your Bates Guide to Physical Examination for excellent examples of
complete H & P and SOAP note formats.

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