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Problem-Focused SOAP Note Format Demographic Data Patient initial (one initial only), age, and gender must be HIPAA compliant. Subjective Chief Complaint (CC) 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, iImmunizations , and preventative health maintenance Family Hx 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 ) Objective Physical findings listed by body systems, not paragraph form Assessment (the diagnosis) Three (3) differential diagnosis (if applicable) with rationale Final diagnosis with rationale and pathophysiological explanation Plan Dx Plan (lab, x-ray) Tx Plan ( meds ) Pt. Education, including specific medication teaching points Referral/Follow-up Health maintenance (including when screenings, immunizations, etc., are next due): Reference Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. Patient information: J.C. 84 yo female Vitals: BP 136/86 Pulse 76 Respirations 18 O2 96% Height 65 Weight 200lbs Came in to clinic for pre-op for kyphoplasty optimization See attachments for detailed patient information as well as a sample paper. There is one more attachment that I cannot add but will send over once professor is selected.

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