SOAP note

SOAP note S: chief complaint ans: OLD CARTS paragraph OLD CARTS ans: Onset Location Duration Characteristics Aggravating/alleviating Radiation/Relieving Treatments Severity/Pain scale S: history ans: SMASH FM bullet points SMASH FM ans: Social history Medications Allergies Surgical history Hospitalizations Family history Past medical history social history ans: FED TACOS FED TACOS ans: Food Exercise Drugs Tobacco Alcohol Caffeine Occupation Sexual History Medications ans: Birth Control Immunizations Allergies ans: Medications Environmental Food Surgery ans: Anatomical Location Year Location of Surgery (Hospital) Hospitalizations ans: Length of Stay Year Location of Stay (Hospital) Family history ans: Marital Status Children Support System at Home Genetics (Cancer, HPN...) Past medical history ans: PMH Recent Illness General Mood (Happy With Life) Review of Symptoms (ROS) ans: Mood, Headaches, Fever, Chills, Sore Throat, Cough, Night Sweats, Day Sweats, Weakness, Fatigue, Nausea, Diarrhea, Vision, Rashes, SOB, Chest Pain, Sleep, Joint Pain, Arthritis Pain, HPN, Urinary Pain, HIV, Pregnancies A, P, closure ans: MOTHRRE MOTHREE ans: Medicine OMM Testing Humanistic Referrals Return Visit ER A,P: Medicines ans: Name, dose, frequency OMM ans: Treatment, type (next visit) Testing ans: Labs (CBC, CMP) diagnostic (X-Ray, CT, MRI, EKG) Humanistic ans: compliance, understanding, ethical issues, support system at home referrals ans: PCP or specialist Return visit ans: I would like to see you again in ____ days/months/year ER ans: if this situation gets worse, please do not hesitate to go straight to the ER