Focused/Episodic Assessment Write-Up Using SOAP Format

One of the goals of this course is for you to learn how to communicate patient information and
your assessment findings by documenting a complete, accurate focused assessment. Writing
H&Ps is an important skill and learning tool. Think of writing your H&P as a means for
integrating all of the information you gather about your patient with what you know and what you
know about certain illnesses to form a coherent, informed argument of what you think is
happening with the patient, why it is happening, and what you want to do.

Faculty will use your write-up for information to evaluate your ability to gather, interpret and
communicate clinical data and your clinical reasoning. Some hints for writing notes are listed
below.

Source and reliability: Who is giving you the history and how reliable are they.

SUBJECTIVE

History
Chief Complaint (CC): This is the Chief Complaint/reason for the visit and should be in the
patient’s own words. EX. This may be a symptom, a laboratory abnormality (e.g. “my doctor
sent me in because my potassium was high”), or another person’s observation (“Mom was
acting confused”). Should be documented in patient’s own words and use only 1 sentence. If
patient is present for a follow up visit, you must give the reason for the follow up.

History of Present Illness (HPI): Think of the HPI as a narrative expanding on the CC, as if
you are telling a story. The HPI should be a sequential (chronological) description of the
patient’s subjective report of experiences/symptoms pertaining to the CC or reason for
encounter. It should include a relevant description of the patient’s complaints and issues,
baseline health, a narrative of the events leading up to the visit, and pertinent positives and
negatives related to the CC/reason for encounter. You should utilize the OLDCART acronym for
this part of the HPI. It should not be a checklist, and it should not include a full PMH or review
of systems. Include pertinent PMH, social history or FH related to CC. Ask if patient has had or
experienced before or what does patient think it is. Although you will find that your HPI
becomes more concise with time, the goal is clarity, not brevity. The HPI should give the reader
a clear picture of the patient’s story and the diagnostic possibilities you are considering by what
you are “ruling out” and “ruling in.” For example, if CC is chest pain, you would not include
patient’s report of nocturia x 10 years in HPI.

Past Medical History (PMH): This is a thorough list of relevant (focused) active and inactive
problems as related by the patient and/or including a problem list from the patient’s past chart
when applicable. You may include some of these problems in the HPI if they are relevant to the
patient’s presenting complaint. These should be listed.

Past Surgical History (PSH): Should include surgery and date. These should be listed.

Medications: Make sure you have a complete list of your patient’s medications, including dose
and how often it is taken. Make sure you understand why your patient is taking each of these
medications. Mentally linking each medication with a problem in the PMH is helpful. Review of

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 prescribed, over-the-counter (OTC) drugs, and/or any alternative or complementary
medications. Listing them makes it easier for you and other practitioners to glance over.

Allergies: Season, contact, food or insect. Drug allergies and always include reaction.

Immunizations:

Family Hx: Relevant Family History: Make sure you ask about whether the chief complaint or
presenting problem also runs in the family. (See page 31-32). Please list.

Social Hx: The psychosocial history should include (but is not limited to) the patient’s living
situation (including caregivers and home nursing/aides) and advanced directives. Diet and
exercise and safety measures should also be included.
Tobacco:

Alcohol:

Drugs:

Review of Systems (ROS): Review of systems includes pertinent to patient problems, chief
complaints, or presenting diagnosis if this is a follow up visit, so not all systems are addressed
in a focused/episodic ROS. This should be thorough as it relates to the HPI. You do not need to
repeat information that you included in the HPI. Remember that this is a part of the subjective
information provided to you by the patient (i.e. subjective information) and not your assessment
from the physical exam (i.e. objective information). This is always done head to toe.

OBJECTIVE

FOCUSED Physical Exam

Your physical exam should be focused and thorough and should include the systems particular
to the chief complaint. For example, a patient with a headache would have an expanded
neurologic exam. Likewise, a patient with abdominal pain would have an expanded abdominal
exam, including maneuvers like a Murphy’s sign, which would not be necessary to do in all
patients. In older adults, consider atypical presentation of illnesses; for example, a UTI often
presents as confusion.
Your discretion should include the need for vital signs, pulse ox, height and weight based on the
reason for the visit. Always listen/document heart and lungs as a part of your PE. Your PE
should be a mirror image of your ROS. This is always done head to toe.

Laboratory Data
Note important trends if available.

Imaging Studies and/or other pertinent testing

(Xrays, MRI’s, CAT Scans, Ultrasounds, etc.)

ASSESSMENT/IMPRESSION – this is your diagnosis. If you can’t make the diagnosis

without additional testing, then use the complaint, ie, chest pain.

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 Differential Diagnoses - For purposes of the course SOAP note assignments, you will need to
include 3 differential diagnoses under consideration. What else could it be based on your history
and PE?

Problem Lists
Should include the patient’s risk factors such as smoking, obesity, FH of DM, etc. It should also
include current diseases and problems. In some cases, the problem will be a symptom
(abdominal pain), if no diagnosis has been made; in other cases, when a problem is established
by the data you have already collected, it will be a diagnosis (pancreatitis).

For more information on a problem list, see pages 37 in your Bates book.

PLAN

Developing a plan may be fairly basic initially and will become more sophisticated as your learn
more. Your plan should include:

 lab studies and any other diagnostic tests

 consultations
 referrals
 nursing and medical interventions such as prescriptions and treatments
 patient/family education and counseling related to the problem identified in your focused
H&P
 follow up care for the next visit (You always need a follow-up visit)

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