Template for Episodic Visit



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Samples of SOAP Notes


Template for Episodic Visit


S: Chief complaint (CC): It is often helpful to use the patient’s report in quotation marks here (i.e., “I am having my period twice a month.”).

History of Present Illness (HPI): Include onset, duration, progression, timing, amount, things that aggravate, things that relieve, treatments already tried, previous history of similar symptoms, etc. Also would include pertinent negatives.

Past Medical History (PMH): Include any pertaining to the chief complaint or that would affect treatment plan.

Current Medications: Include all and don’t forget to ask about alternative remedies.

Allergies

Psychosocial and Family History: Include any that pertains to the chief complaint or that would affect treatment plan.

Social History/Habits: Include use of tobacco, drugs and alcohol as well as social history that may affect the treatment plan.
O: Vital signs if they are not listed elsewhere on this page.

General: Is the patient anxious, nervous, or in pain? Does she look older than stated age? Can use NAD (no apparent distress).

Physical Exam: Include only those systems pertaining to the chief complaint. Organize by systems and list in head to toe order.

Diagnostic: List results that you have (lab, x-ray, etc.).


A: Diagnosis: Written at your level of understanding of the problem and based on the subjective and objective data that you have presented.
P: 1) Diagnostic (lab, x-ray, EKG, other) that you plan for this patient.

2) Treatment

3) Education

4) Consultation, Collaboration or Referral

5) Follow-up

Remember that for every S (complaint), there must be an O, A, and P (relevant exam, diagnosis and plan). Always sign your notes.



Example: Physical Exam


S: 27yr old female/male presents for physical exam (add additional needs such as employment/sports/etc.)

May add additional concern under “Additional Chief Concern” with description as in episodic visit above.

PMH: Past Hx of or current medical conditions/Recent positive findings in diagnostic tests/Surgical hx/Vaccines

Sexual/Reproductive Hx: if indicated. Include cycles/birth control/sexual partners/STD hx

Current Meds:

Allergies: list or NKDA.

FMH: Major diseases in sibs, parents, grandparents, other pertinent

ROS: Constitutional, EENT, Resp, CV, GI, GU, Musc, Skin/breasts, Neuro, Endo, Heme/lymph, Allery/immune, Psych

Social/Lifestyle History: Use of tobacco, alcohol or recreational drugs. Seat belts.

Nutrition. Exercise. Hx of abuse. Pertinent relationships. Occupation stresses. Situational life crises.


O: General: no apparent distress

HEENMT: Normocephalic. EOMs intact, PERRLA. TMs pearly grey bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.

Neck: No lymphadenopathy or thyromegaly.

Resp: clear throughout

Heart: RRR, no m, g or r.

Breasts: Fibrocystic changes, no masses or tenderness.

Abdomen: Non-tender, no hepatosplenomegaly.

Extremities: FROM, no varicosities.

Pelvic exam:

External genitalia: Triangle eschucheon, no lesions.

Vagina: Rugated, white discharge, no odor, pH 4.5.

Cervix: 3X3 cm, no motion tenderness, patent os without discharge, no lesions.

Uterus: Small, mobile, midline, anteverted, non-tender.

Adnexae: No masses or tenderness bilaterally.

GU: Scrotum, Penis, Prostate, Urethra

Musc/skel: Gait, ROM, Stability, Strength

Skin:

Neuro: CN, DTR, Sensation




A: Normal exam or pertinent findings.
P: 1) Diagnostic (lab, x-ray, EKG, other) that you plan for this patient.

2) Treatment

3) Education

4) Consultation, Collaboration or Referral

5) Follow-up


Breast Exam Documentation


Normal Exam: Size (if remarkable). Symmetric. Nipples (number, placement, inversion, discharge). Skin changes (rashes, lesions, dimpling, retraction). Note masses or tenderness.
Description of a Mass: Location, size, shape, consistency, mobility, distinctness, nipple, skin over lump, tenderness to palpation, lymphadenopathy.

Pelvic Exam Documentation


External Genitalia:

Hair distribution, labia majora and minora, Bartholins and Skenes glands (often grouped with urethra and abbreviated BUS), hymen, introitus, perineum.

Note any masses, lesions, excoriation, erythema, tenderness or discharge.
Internal Genitalia:

Vagina: Color, rugation, tone. Note cystocele, rectocele, discharge.

Cervix: Color, os, position, texuture, mobility. Note lesions, discharge, CMT.

Uterus: Position, size, mobility. Note masses or tenderness.



Adnexae: Size. Note masses or tenderness.


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