Guide for SOAP Notes – updated 6/13
S: Subjective information - Patient description and chief complaint, HX of present
illness (how long they have been sick), 7 critical characteristics (all that apply):
Location
Character or Quality
Quantity or Severity (1-10)
Timing
Setting
Aggravating or Relieving Factors
Associated Factors (ROS – head to toe review of systems – with a focus on the chief
complaint)
Ask about food & fluid intake,
past medical hx, significant family hx, sick contacts & recent travel (if appropriate),
tobacco, ETOH, drugs, immunizations (up to date), medications (RX, OTC, herbal),
allergies, sexually active, contraception use, LMP & last pap (if female patient), any other
concerns or complaints
O: Physical Assessment
General Survey – ie: obese female, fatigued, flat affect, NAD
ie: alert, friendly, interactive, well appearing black male, NAD
ie: white female, tearful, sad, pale, unkempt, mild distress
Exam: (Focused exam should always include eyes (look at sclera and pupils), mouth
(look at mucosa and throat), neck (check nodes), lungs and heart (lungs sounds and
listen for murmur)
Vital signs: BP, HR, Resp, Temp
(Keep exam focused based on subjective data)
Head
Eyes
Ears
Nose
Mouth/throat
Neck
Lungs
Heart
Abd
Genitalia
Musculoskeletal
Neuro
Differential Diagnosis: (list differentials 2 - 3)
A: Diagnosis –
P: Plan – labs, diagnostic tests, prescriptions, plan of action, instructions & follow-up
This study source was downloaded by 100000804166229 from CourseHero.com on 04-18-2022 06:45:11 GMT -05:00
https://www.coursehero.com/file/94064437/SOAP-guide-2013-1doc/
S: Subjective information - Patient description and chief complaint, HX of present
illness (how long they have been sick), 7 critical characteristics (all that apply):
Location
Character or Quality
Quantity or Severity (1-10)
Timing
Setting
Aggravating or Relieving Factors
Associated Factors (ROS – head to toe review of systems – with a focus on the chief
complaint)
Ask about food & fluid intake,
past medical hx, significant family hx, sick contacts & recent travel (if appropriate),
tobacco, ETOH, drugs, immunizations (up to date), medications (RX, OTC, herbal),
allergies, sexually active, contraception use, LMP & last pap (if female patient), any other
concerns or complaints
O: Physical Assessment
General Survey – ie: obese female, fatigued, flat affect, NAD
ie: alert, friendly, interactive, well appearing black male, NAD
ie: white female, tearful, sad, pale, unkempt, mild distress
Exam: (Focused exam should always include eyes (look at sclera and pupils), mouth
(look at mucosa and throat), neck (check nodes), lungs and heart (lungs sounds and
listen for murmur)
Vital signs: BP, HR, Resp, Temp
(Keep exam focused based on subjective data)
Head
Eyes
Ears
Nose
Mouth/throat
Neck
Lungs
Heart
Abd
Genitalia
Musculoskeletal
Neuro
Differential Diagnosis: (list differentials 2 - 3)
A: Diagnosis –
P: Plan – labs, diagnostic tests, prescriptions, plan of action, instructions & follow-up
This study source was downloaded by 100000804166229 from CourseHero.com on 04-18-2022 06:45:11 GMT -05:00
https://www.coursehero.com/file/94064437/SOAP-guide-2013-1doc/
