How to Write a SOAP Note
Example Chief Complaint: Medication Refill
S:
[Subjective – what the patient tells you. Include HPI (“oldcarts”), pertinent (+) and (-) on ROS, PMH, Family/Social History]
O:
[Objective – mental status exam, physical exam findings, lab values]
A / P:
[Assessment and Plan –problem list, provide assessment, describe plan]
EXAMPLE NOTE:
S: Pt is a 54 year old female presenting for refill on HCTZ / Lisinopril 12.5/10mg and Metformin 500mg. Patient was last seen at clinic on 7/21/13. Patient denies headaches, vision changes, chest pain, or SOB. Patient denies numbness or tingling in hands/feet, N/V/D, polyuria, nocturia. Reported BGs ~130. BPs ~130/85. Patient lives with wife, smokes 1 pack per day. No drugs / EtOH.
O: Patient is casually dressed, cooperative, and friendly. A&Ox3. VSS.
Revised 2/25/14. Email with any feedback.
HEENT: NCAT, TMs visible, no pharyngeal erythema. EOMI.
Cardio: RRR. No murmurs or gallops,
no edema, strong S1, S2.
Resp: Lungs CTAB. non-labored breathing.
Revised 2/25/14. Email with any feedback.
LABS: A1c: 6.6; Microalbumin: negative
A/P:
(1) HTN – controlled. Continue HCTZ / Lisinopril 12.5/10mg 1 tab PO daily.
Encourage diet and exercise.
(2) DM - controlled. Continue Metformin 500mg PO daily.
Encourage daily fasting blood sugar check.
Encourage low carb intake.
Labs ordered: A1c, lipid panel, iStat, urine for microalbumin
Abbreviations to Know:
Revised 2/25/14. Email with any feedback.
N/V/D – nausea, vomiting, diarrhea
VSS – vital signs stable
A&Ox3 - alert and orientated to person, place, and time
NCAT – Normocephalic, atraumatic
TM – Tympanic membranes
EOMI – Extraocular movements intact
RRR – Regular rate and rhythm
CTAB- Clear to auscultation bilaterally
Revised 2/25/14. Email with any feedback.
How to Present a Patient to an Attending
Order of information can be dependent on the resident but a decent guideline:
[Basic Information: Name, Age, Race, Chief complaint, relevant PMH]
[HPI – OLDCARTS or basic Subjective. Pertinent ROS]
[Other Past Medical or Surgical History if relevant]
[Relevant Family History or Social History]
[Current Meds and Allergies]
[Pertinent Physical Exam Findings]
[Pertinent Lab Values]
[Overall Assessment / List of Problems + Answer any questions]*
[Plan for Each Problem]
“Mr. Lopez is a 54 year old Hispanic male with a 3 day history of sore throat, productive cough, runny nose and nasal congestion. He has been taking ibuprofen for the throat pain but nothing for the runny nose. No reported fevers, ear pain, eye pain, vomiting or diarrhea.
He has a past medical history of hypertension, controlled on HCTZ. He has two kids at home who were sick last week. He is only taking HCTZ and ibuprofen and has no reported allergies except seasonal allergies. He does not drink or do drugs but smokes about one pack a day with a 34 pack-year history.
On physical exam, he has enlarged tonsils that look red and inflamed and his nasal turbinates look swollen. No fevers, sinus tenderness, or redness in the ears. Heart and lungs sound good.“
How to Write A Prescription
Revised 2/25/14. Email with any feedback.
[Drug Name] [Strength]
Dispense [Number of pills] [spelled out]
[Amount] [Route] [Frequency]
Metformin 500mg
Dispense #60 (sixty)
1 tab PO BID
Revised 2/25/14. Email with any feedback.
Abbreviations to Know:
Revised 2/25/14. Email with any feedback.
PRN – as needed
BID – twice a day
TID – three times a day
QHS – at bedtime
QAM – in the morning
Revised 2/25/14. Email with any feedback.
Revised 2/25/14. Email with any feedback.
Revised 2/25/14. Email with any feedback.
Revised 2/25/14. Email with any feedback.