Week 5 Problem-Focused SOAP Note
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)
• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological
explanation
• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent
positives and negatives for each
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
Reference
• Compare care given to the patient with the National Standards of Care/National
Guidelines. Cite accordingly.
Rubric Problem-focused SOAP Note
Problem-focused SOAP Note
Criteria Ratings Pts
This criterion is linked to a
Learning Outcome Subjective
12.5 to >11.5 pts
Accomplished
Symptom analysis is well organized, with C/C,
OLDCART, pertinent negatives, and pertinent
positives. All data needed to support the diagnosis
& differential are present. Is complete, concise,
relevant with no extraneous data.
12.5 pts
This criterion is linked to a
Learning Outcome Objective
12.5 to >11.5 pts
Accomplished
Complete, concise, well organized and well
written and includes pertinent positive and
pertinent negative physical findings. Organized
by body system in list format. No extraneous
data.
12.5 pts
This criterion is linked to a
Learning Outcome Assessment
12.5 to >11.5 pts
Accomplished
Diagnosis and differential dx are correct with ICD
code and supported by subjective and objective
data.
12.5 pts
This criterion is linked to a
Learning Outcome Plan
12.5 to >11.5 pts
Accomplished
Plan is organized, complete and evidence-based
according to National Standards of Care.
Addresses each diagnosis and is individualized to
the specific patient and includes medication
teaching and all 5 components: (Dx plan, Tx plan,
patient education, referral/follow-up, health
maintenance).
12.5 pts
Total Points: 50
• Can you make pediatric soap note? I can give you one example, but you can change it. However,
it needs one working diagnosis with two different differential diagnoses with rationale and
pertinent positives and negatives for each. Plus ICD 10 code and cpt code.
My example case
16 yrs old male: All labs are WNL. Complains chronic Acne on face, fatigue, insomnia. Spanish
speaking, Low income. Playing video games almost all night. Prescribed Doxycycline 100mg PO
BID for two weeks no refill, Clindamycin 1% topical lotion twice a day 60 gram no refill, and
hydrogen peroxide gel for acne as prn with 2 times refills. Told mom not to play video games at
night.
However, you can change the case to other pediatric cases such as UTI, dermatitis, pruritus etc
- Week 5 Problem-Focused SOAP Note
- Rubric
