TW soap note
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Use the “OLDCART” approach for collecting data and documenting
findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment,
S=summary]
PMH: This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of
use.
SH Related to the problem, educational level/literacy, smoking, alcohol,
drugs, HIV risk, sexually active, caffeine, work and other stressors.
Cultural and spiritual beliefs that impact health and illness. Financial
resources.
FH Use terms like maternal, paternal, and the diseases along with the ages
they were deceased or diagnosed if known.
HEALTH
PROMOTION &
MAINTENANCE
Required for all SOAP notes: Immunizations, exercise, diet, etc.
Remember to use the United States Clinical Preventative Services Task
Force (USPSTF) for age-appropriate indicators. This should reflect what
the patient is presently doing regarding the guidelines. Other wellness
visits including but not limited to dental and eye exams.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral
Vascular
Respiratory
Breast
Gastrointestinal
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
VITALS: HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
Age: LMP: PAIN:
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1.
2.
3.
VISIT CODES CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned
for/ordered during the encounter that you plan to review/evaluate
relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full
prescribing information for any pharmacologic interventions
including quantity and number of refills for any new or refilled
medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no
refills)
Education: information clients need in order to address their health
problems. Include follow-up care. Anticipatory guidance and
counseling.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Consultation/Collaboration: referrals or consult while in clinic with
another provider. If no referral made was there a possible referral
you could make and why? Advance care planning.
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP
