Use the format below for your SOAP note.
Use current APA format to style your paper and to cite your sources. Problem-focused SOAP Note Format Demographic Data
Subjective: Chief Complaint: 21 year old , female who comes in to the clinic with complaints of pelvic tenderness and intermittent vaginal discharge. She states she received her 1st HPV vaccine as a teenager but never received her second dose. History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Mention also Last menstrual period, Last Pap or pelvic exam Birth control method and gender preference.
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Two (2) differential diagnosis (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation
Dx Plan (lab, x-ray)
Tx Plan (meds)
Pt. Education, including specific medication teaching points
Health maintenance (including when screenings, immunizations, etc., are next due) (Recommendations on this website -USPSTF)
Compare care given to the patient with the National Standards of Care/National Guidelines . Cite accordingly.
Use the format below for your SOAP note. Use current APA format to style your pa
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Use the format below for your SOAP note.
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