Compare and Contrast: Complete H&P and SOAP Note

Full (complete) H&P “SOAP”

ID ID
CC CC
SUBJECTIVE
HPI HPI
PMH PMH (pertinent)
Medication
Social History SH (pertinent)
Family History FH (pertinent)
Meds
ROS ROS
OBJECTIVE
PE/labs/Studies PE/labs/studies
Assessment/Synthesis/Summary Statement ASSESSMENT
Assessment/Synthesis/Summary Statement
Plan PLAN

In Doctoring 1, you learned how to write a complete H&P. In order to facilitate a

standard method for providing patient information, clinicians will often use the
SOAP format for both writing notes and presenting patients on rounds.

When do you do a complete H&P?

Admitting a patient to the hospital
Seeing a new patient that will establish care with you in an outpatient setting
Annual visits for pediatric patients, women, and men
Other??

When do you do a SOAP Note?

Follow-up clinic visits
Daily progress notes for patients admitted to the hospital
Other??