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    SOAP Notes Format in EMR: SOAP Stands For Subjective, Objective, Assessment, and Plan

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    Nick Jacob
    This document provides an example of the standard SOAP (Subjective, Objective, Assessment, Plan) notes format used in electronic medical records. It includes sections for documenting date, time, provider, vital signs, history of present illness, review of systems, past medical history, physical exam findings, assessment, and plan. The physical exam section lists normal findings for each body system as an example.

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    SOAP Notes Format in EMR: SOAP Stands For Subjective, Objective, Assessment, and Plan

    Uploaded by

    Nick Jacob
    3K views2 pages
    This document provides an example of the standard SOAP (Subjective, Objective, Assessment, Plan) notes format used in electronic medical records. It includes sections for documenting date, time, provider, vital signs, history of present illness, review of systems, past medical history, physical exam findings, assessment, and plan. The physical exam section lists normal findings for each body system as an example.

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    SOAP notes

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    SOAP note

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    This document provides an example of the standard SOAP (Subjective, Objective, Assessment, Plan) notes format used in electronic medical records. It includes sections for documenting date, time, provider, vital signs, history of present illness, review of systems, past medical history, physical exam findings, assessment, and plan. The physical exam section lists normal findings for each body system as an example.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views2 pages

    SOAP Notes Format in EMR: SOAP Stands For Subjective, Objective, Assessment, and Plan

    Uploaded by

    Nick Jacob
    This document provides an example of the standard SOAP (Subjective, Objective, Assessment, Plan) notes format used in electronic medical records. It includes sections for documenting date, time, provider, vital signs, history of present illness, review of systems, past medical history, physical exam findings, assessment, and plan. The physical exam section lists normal findings for each body system as an example.

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    SOAP Notes Format in EMR

    SOAP stands for Subjective, Objective, Assessment, and Plan


    Standard Elements of SOAPnote
    Date: 08/01/02
    Time:
    Provider:
    Vital Signs:
    Height, Weight, Temp, B/P, Pulse

    S: This ___ yr old fe/male presents for ____


    History of Present Illness symptoms:
    Review Of Symptoms/Systems: (For problem-focused visit, document only pertinent information)
    Past Medical History: (For problem-focused visit, document only pertinent information)
    Current Medications:
    Medication allergies:
    Social History: (For problem-focused visit, document only pertinent information)
    Family History: ((For problem-focused visit, document only pertinent information)
    Genogram: 3 generations with health problems, causes of deaths, etc.
    or
    History of major health or genetic disorders in family, including early death, spontaneous abortions
    or stillbirths.

    Past Medical History


    Hospitalizations:
    Surgical History:
    T&A:
    Appendectomy:
    Hysterectomy:
    Hernia:
    Coronary Artery Bypass:
    Other:
    Chronic Medical Problems:
    Hypertension
    Diabetes
    Coronary Heart Disease
    Cerebrovascular Disease
    Asthma or other COPD
    Arthritis
    Gout
    Renal Disease
    Thyroid Disease
    Other:
    Psychiatric History:
    Depression
    Anxiety
    Substance Abuse
    Other:
    Immunizations:
    Polio
    Tetanus
    Last PPD
    Cholera
    Childhood Illnesses:
    Transfusions:
    Allergies:

    History of Present Illness:


    Location:
    Quality
    Severity:
    Duration:
    Timing (Onset):
    Timing (Frequency):
    Context:
    Relieved by:
    Worsened by:
    Associated signs and symptoms:

    Review Of Symptoms (Systems):


    Constitutional:
    Eyes:
    Ears, Nose, Mouth, Throat:
    Cardiovascular:
    Respiratory:
    Gastrointestinal:
    Genitourinary:
    Musculoskeletal:
    Skin and/or breasts:
    Neurological:
    Psychiatric:
    Endocrine:
    Hematologic/Lymphatic:
    Allergic/Immunologic:

    \\cluster1\home\nancy.clark\1 Training\EMR\SOAP Note.doc

    Social History:
    Cultural Background:
    Education Level:
    Economic Condition:
    Housing:
    Number in household:
    Marital Status:
    Lives with:
    Children:
    Occupation:
    Occupational Health
    Hazards:
    Nutrition:
    Exercise:
    Tobacco use:
    Caffeine:
    Sexual activity:
    Contraception:
    Alcohol/recreational drug
    use:
    Family History
    Is there a family history of
    Cancer:
    Hypertension:
    Hyperlipidemia:
    Diabetes Type II:
    Coronary Artery Disease:
    Stroke:
    Alzheimer's:
    Depression:
    Osteoporosis:
    Domestic violence:

    O:

    (listed are the components of the all normal physical exam)


    General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect .
    Ambulating without difficulty.
    Skin: Good turgor, no rash, unusual bruising or prominent lesions
    Hair: Normal texture and distribution.
    Nails: Normal color, no deformities
    HEENT:
    Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
    Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi
    have normal optic discs and vessels, no exudates or hemorrhages
    Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
    Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
    Mouth: Mucous membranes moist, no mucosal lesions.
    Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant
    resorption.
    Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
    Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
    Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
    Lungs: Clear to auscultation and percussion
    Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
    Back: Spine normal without deformity or tenderness, no CVA tenderness
    Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
    Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses
    intact
    Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects,
    tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal
    strength or tone in the head, neck, spine, ribs, pelvis or extremities.
    Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
    in upper and lower extremities. No pathologic reflexes.
    Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, normal mood
    and affect.
    Pelvic: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametria nontender
    without masses.
    Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or
    supraclavicular adenopathy.
    G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes
    and epididymides normal size without masses, scrotum without lesions.

    A:
    Assessment:
    Includes health status and need for lifestyle changes.
    Diagnosis and differential diagnosis:

    P:
    Laboratory:
    X-Rays:
    Medications:
    Patient Education:
    Other:
    Follow-up:

    \\cluster1\home\nancy.clark\1 Training\EMR\SOAP Note.doc

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