A Well Visit SOAP Note

SOAP NOTE GUIDE and RUBRIC

The SOAP note should mimic clinical documentation in the practicum setting. The documentation should be accurate, clear, well organized and utilizes medical terminology.

For comprehensive SOAP note, if it is a well visit and you do not have differential diagnoses, just provide rationale for the health promotion/prevention interventions included.

SUBJECTIVE (20 points)

CC – the reason for the visit as stated in the patient’s own words

Example: “I have been coughing frequently for 5 days.”

HPI (History of Present Illness) – include symptom dimensions, chronological narrative of patient’s complains. Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. If the information is obtained from other sources, always identify source.

PMH (Pertinent past medical history)

Medications – Current medications (list with daily dosages).

Allergies

Pertinent Family History, Social History and other subjective data if relevant to the patient’s presenting problem and diagnosis.

ROS (Pertinent review of systems) – a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis.

OBJECTIVE (20 points)

Vital signs

PE – focused physical exam finding limited to systems pertinent to the problem

Laboratory or diagnostic data if applicable

ASSESSMENT (Problem List) with ICD-10 Codes

This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes or progress in the status of the problems. List the problem list (diagnosis/es) in order of importance.

The assessment could also contain the possible causes of the patient’s problem, especially if the patient is experiencing an illness.

If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.

Example:

#1 acute viral bronchitis (J20.9) – Mr. X is a 54 yr old man with HTN presents with frequent cough x 5 days, worse at night with small amount whitish sputum, denies SOB, fever and chills. Lungs clear, fremitus is equal and there is no egophony. Most likely acute viral bronchitis.

#2 HTN, controlled (I10)

PLAN

This has to be evidence based using the latest clinical guideline. This should include pharmacologic, non-pharmacologic, education, referrals and follow-up – when applicable. The plan should be personalized and appropriate for the patient. The plan should address all the problems in Assessment.

Example:

#1 acute viral bronchitis (J20.9)

– supportive care, no antibiotic therapy

– OTC Dextromethorphan/guaifenesin 10ml Q4hrs

– Avoid decongestants due to HTN

– Follow up in 1 week if no improvement or if condition worsens, a CXR can be done to r/o pneumonia.

#2 HTN, controlled

– continue amlodipine 5 mg daily.

– Low Na diet discussed

Evidence- Based Rationale (20 points)

– Identify 3 differential diagnoses considered. Provide a brief rationale for each differential diagnosis (3-4 sentences) – rationale should provide data that support your differential diagnoses – presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis. Cite.

– Briefly discuss the rationale of the plan. Include clinical guidelines used, cite.

Grading will be based on the following criteria:

Subjective Data: Subjective assessment of health status is fully explicated. CC is succinct. HPI information is fully developed and included. Elements of the PMH, FH, and ROS that expand on the CC and HP information are included. 20%

Objective Data: Objective assessment of health status is fully explicated. Includes appropriate

and relevant data. 20%

Assessment with ICD 10 code/s: Accurate problem identification and prioritization supported

logically by the subjective and objective data. Exhibits clear understanding of the patient’s

current condition(s).

Complete problem list identified (when applicable) with an optimal assessment for each problem.

ICD-10 codes are included and accurate. 20%

Plan: Plan is appropriate and specific for diagnosis, adequately addresses the problem/s identified

and utilizes latest clinical guidelines. Plan is economically sound. 20%

Evidence- Based Rationale

– Identify 3 differential diagnoses with rationale, cite.

– Briefly discuss the rationale of the plan. Include clinical guidelines used, cite. 20%

Total 100%