COVER SHEET
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom (write in narrative form) DO NOT LIST:
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): List Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History:Tobacco use, Alcohol use, Drug use, Tattoos, Piercings. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Current or Retired vocation.
Immunizations: Last Tdp, Flu, pneumonia, etc.
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. It is SUBJECTIVE. It should be documented as denies or states… It should include health screenings for each system (last dental exam, mammogram, pelvic exam, colonoscopy etc.)
General: any recent weight changes, weakness, fatigue, or fever
Skin: rashes, lumps, sores, itching, dryness, changes, etc.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Peripheral vascular:
Urinary:
Genital:
Musculoskeletal:
Psychiatric:
Neurological:
Hematologic:
Endocrine:
OBJECTIVE DATA: This is what you see, hear, feel when doing your physical exam. It is OBJECTIVE.Again, you go head to toe and you only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P.Do not use WNL or normal. You must describe what you see.
Here is where the vital signs go. Include ht and wt and BMI
General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.
SKIN:
HEENT:
Neck:
Chest/Lungs: ALWAYS INCLUDE IN YOUR PE
Heart/Peripheral Vascular: ALWAYS INCLUDE THE HEART IN YOUR PE
Abdomen:
Genital:
Musculoskeletal:
Neurological:
ASSESSMENT: Need to list your priority diagnosis(es) first. For each priority diagnosis, list at least 3 differential diagnoses. Support your selection with evidence.
Example: Migraine headache (tension headache, cluster headache, brain tumor)
Hypertension (renal disease, stress, renal artery stenosis)
For holistic care you need to include previous diagnoses and indicate whether these are controlled or not controlled and remember to include that in your treatment plan.
What evidence or guidelines did you use to support your diagnoses
Include ALL areas listed below:
PLAN: Treatment plan. Labs, x-rays, etc. Include both pharmacological and nonpharmacological strategies. Include alternative therapies. When do they need to follow-up Any referrals Consultations
HEALTH PROMOTION: What does the patient family need to do to promote their health Exercise, healthy diet, safety, etc.
DISEASE PREVENTION: For the patient’s age, what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc.
EVIDENCE-BASED PRACTICE: What evidence did you use to support your treatment plan
REFLECTION: What did you learn from this experience What would you do differently Do you agree with your preceptor based on the evidence Really think about what you are doing in clinical.
REFERENCE SHEET: Separate page; should include a Health Assessment Text