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Soap Routine

This document provides templates for documenting SOAP notes for episodic visits and physical exams. For episodic visits, the S (subjective) section includes the chief complaint, history of present illness, past medical history, current medications, allergies, and psychosocial history. The O (objective) section includes vital signs and physical exam findings. The A (assessment) section states the diagnosis. The P (plan) section lists the treatment plan. For physical exams, the S section includes the history and ROS. The O section documents the physical exam by system. The A section states findings. The P section lists the treatment plan. Documentation templates are provided for breast and pelvic exams.

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Roberto Ramos
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© © All Rights Reserved
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Download as RTF, PDF, TXT or read online on Scribd
393 views

Soap Routine

This document provides templates for documenting SOAP notes for episodic visits and physical exams. For episodic visits, the S (subjective) section includes the chief complaint, history of present illness, past medical history, current medications, allergies, and psychosocial history. The O (objective) section includes vital signs and physical exam findings. The A (assessment) section states the diagnosis. The P (plan) section lists the treatment plan. For physical exams, the S section includes the history and ROS. The O section documents the physical exam by system. The A section states findings. The P section lists the treatment plan. Documentation templates are provided for breast and pelvic exams.

Uploaded by

Roberto Ramos
Copyright
© © All Rights Reserved
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
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Frontier Nursing University

Samples of SOAP Notes

Template for Episodic Visit


S: Chief complaint (CC): It is often helpful to use the patients report in quotation marks
here (i.e., I am having my period twice a month.).
History of Present Illness (HPI): Include onset, duration, progression, timing, amount,
things that aggravate, things that relieve, treatments already tried, previous history of
similar symptoms, etc. Also would include pertinent negatives.
Past Medical History (PMH): Include any pertaining to the chief complaint or that
would affect treatment plan.
Current Medications: Include all and dont forget to ask about alternative remedies.
Allergies
Psychosocial and Family History: Include any that pertains to the chief complaint or
that would affect treatment plan.
Social History/Habits: Include use of tobacco, drugs and alcohol as well as social
history that may affect the treatment plan.
O: Vital signs if they are not listed elsewhere on this page.
General: Is the patient anxious, nervous, or in pain? Does she look older than stated
age? Can use NAD (no apparent distress).
Physical Exam: Include only those systems pertaining to the chief complaint.
Organize by systems and list in head to toe order.
Diagnostic: List results that you have (lab, x-ray, etc.).
A: Diagnosis: Written at your level of understanding of the problem and based on the
subjective and
objective data that you have presented.
P: 1)
2)
3)
4)
5)

Diagnostic (lab, x-ray, EKG, other) that you plan for this patient.
Treatment
Education
Consultation, Collaboration or Referral
Follow-up

Remember that for every S (complaint), there must be an O, A, and P (relevant exam,
diagnosis and plan). Always sign your notes.

Example: Physical Exam


S: 27yr old female/male presents for physical exam (add additional needs such as
employment/sports/etc.)

May add additional concern under Additional Chief Concern with description as in
episodic visit above.
PMH: Past Hx of or current medical conditions/Recent positive findings in diagnostic
tests/Surgical hx/Vaccines
Sexual/Reproductive Hx: if indicated. Include cycles/birth control/sexual
partners/STD hx
Current Meds:
Allergies: list or NKDA.
FMH: Major diseases in sibs, parents, grandparents, other pertinent
ROS: Constitutional, EENT, Resp, CV, GI, GU, Musc, Skin/breasts, Neuro, Endo,
Heme/lymph, Allery/immune, Psych
Social/Lifestyle History: Use of tobacco, alcohol or recreational drugs. Seat belts.
Nutrition. Exercise. Hx of abuse. Pertinent relationships. Occupation stresses. Situational
life crises.
O: General: no apparent distress
HEENMT: Normocephalic. EOMs intact, PERRLA. TMs pearly grey bilaterally.
No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good
repair, gums pink.
Neck: No lymphadenopathy or thyromegaly.
Resp: clear throughout
Heart: RRR, no m, g or r.
Breasts: Fibrocystic changes, no masses or tenderness.
Abdomen: Non-tender, no hepatosplenomegaly.
Extremities: FROM, no varicosities.
Pelvic exam:
External genitalia: Triangle eschucheon, no lesions.
Vagina: Rugated, white discharge, no odor, pH 4.5.
Cervix: 3X3 cm, no motion tenderness, patent os without discharge, no lesions.
Uterus: Small, mobile, midline, anteverted, non-tender.
Adnexae: No masses or tenderness bilaterally.
GU: Scrotum, Penis, Prostate, Urethra
Musc/skel: Gait, ROM, Stability, Strength
Skin:
Neuro: CN, DTR, Sensation
A: Normal exam or pertinent findings.
P: 1)
2)
3)
4)
5)

Diagnostic (lab, x-ray, EKG, other) that you plan for this patient.
Treatment
Education
Consultation, Collaboration or Referral
Follow-up

Breast Exam Documentation


Normal Exam: Size (if remarkable). Symmetric. Nipples (number, placement, inversion,
discharge). Skin changes (rashes, lesions, dimpling, retraction). Note masses or
tenderness.
Description of a Mass: Location, size, shape, consistency, mobility, distinctness, nipple,
skin over lump, tenderness to palpation, lymphadenopathy.
Pelvic Exam Documentation
External Genitalia:
Hair distribution, labia majora and minora, Bartholins and Skenes glands (often grouped
with urethra and abbreviated BUS), hymen, introitus, perineum.
Note any masses, lesions, excoriation, erythema, tenderness or discharge.
Internal Genitalia:
Vagina: Color, rugation, tone. Note cystocele, rectocele, discharge.
Cervix: Color, os, position, texuture, mobility. Note lesions, discharge, CMT.
Uterus: Position, size, mobility. Note masses or tenderness.
Adnexae: Size. Note masses or tenderness.

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