Clinical Documentation Template
Directions: Students may use this general SOAP note template or their own. Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.
Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:
Delete all text in red – these are instructions and not part of the SOAP document.
Student Name and clinical course: (If no title page): ______________________
ID:
Client’s Initials*:_______Age_____ Race__________Gender____________Date of Birth___________
Insurance _______________ Marital Status_____________
*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.
Subjective:
CC: Patient’s own words, a few words, a sentence or less. Example: “cough and fever”
HPI:
In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.
Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.
Past Medical History:
· Medical problem list
· Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)
· Surgeries:
· Hospitalizations:
· LMP, pregnancy status, menopause, etc. for women
Allergies:
Food, drug, environmental
Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use
Family History:
Social History:
-Sexual history and contraception/protection (as applies to the case)
-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)
Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)
ROS (write out by system): Comprehensive ( >10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.
Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Objective
Vital Signs: HR BP Temp RR SpO2 Pain
Height Weight BMI (be sure to include percentiles for peds)
Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today
Physical Exam (write out by system):
Start with a general survey:
Assessment
(you will often have more than one diagnosis/problem, but do the differential on the main problem)
Differentials (with a brief rationale for each):
1.
2.
3.
Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)
Plan (4 pronged-plan for each problem on the problem list)
Diagnostics:
Treatment:
Education
Follow Up:
List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed
2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when sick
E. Return to clinic in 3-4 months to reassess
