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SOAP NOTES

Alesia Wagner, DO, FACOPF dist.

Spring 2020 OD 2
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Objectives: The student will be able to:

 Document the details of a clinical encounter in the form of a SOAP

note

 Ensure the note appropriately reflects the patient encounter for the
next physician or member of the medical team

 Provide a working diagnosis and differential diagnoses with support

 Create an appropriate 6-point treatment plan, including reasoning for

any diagnostic tests
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History (SUBJECTIVE = S)

 Incorporate chief complaint into an introductory summary sentence

 History of Present Illness

 Includes OLDCARTS where appropriate
 Includes higher order questions to further delineate the patient’s story
 Associated manifestations (ROS)

 PMH, PSH, Trauma, Family and Social History

 New patient – will have more detail
 Existing patient – will need relevant components

 Allergy History and Medications – detailed at every visit

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Physical Examination (Objective = O)

 ALWAYS start with a description of the patient

 Write out the vital signs if they are not pre-populated in the document; if
they are n the document, describe them (vital signs stable – for example)

 Document appropriate positives and pertinent negatives on the exam

 Document ONLY what you actually performed!
 Don’t forget inspection in your documentation
 Integrate your structural exam with the appropriate body system(s)

 Any diagnostic studies available go in the objective section

+ Working Diagnosis & Differential Diagnoses
(Assessment = A)

 Working Diagnosis
 For rotations, you will not document your supporting information here.
 For our notes, we want you to get into the habit of clinically reasoning
your choices, so list the supporting information from history and physical

 Differential Diagnoses (DDx)

 3 DDx
 List in order of most likely to least likely
 Note if life or limb threatening
 Supply 1-2 reasons why this is not the working diagnosis
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Other Considerations to Assessment

 Somatic Dysfunctions can be listed as a separate diagnosis

 If done as separate Dx, then needs a brief plan

 If patient has other conditions, should be listed as secondary or

tertiary diagnoses and have a brief plan
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Treatment Plan (Plan = P)
 Medication
 Name of drug
 Once on rotations, you will work on strength and dosing
 Includes IV fluids, OTC meds, oxygen

 Diagnostic Studies
 Lab – name specific tests and why you are ordering them; avoid “panels”
 Imaging – name specific studies and why your are ordering them
 Other – includes EKG, PFT

 OMM – name specific treatments for the somatic dysfunctions

identified; consider things like rib raising if there is cough, opening
diaphragm or thoracic inlet if infections.
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Plan continued

 Patient Education
 Needs things specific to the diagnosis
 Avoid saying increase fluids for all (as an example)

 Follow up
 When to see you again
 Referral to ED or for admission to hospital
 Referral to specialist and why