SOAP Note Clinical Documentation

AGACNP SOAP Note Instructions/Template

All sections of the SOAP note should be addressed relevant to the presenting chief

complaint and/or hospitalization.

CLINICAL DATE:

TYPE OF NOTE: Comprehensive (Admission- H&P, Transfer Services, Emergency

Department Note, Progress Note and Discharge Note) vs. Focus (Consult Note, Progress Note,

and Emergency Department Note)

Subjective (This section includes only what the patient tells you.)

CC: Chief complaint What are they being seen for? This is the reason that the patient sought

care, stated in their own words/words of their caregiver, or paraphrased.

HPI: History of present illness use the OLDCART approach for collecting data and

documenting findings. [O= onset, L= location, D=duration, C=characteristics, A=

associated/aggravating factors, R=relieving factors, T=treatment, S=summary]. Provide this in

narrative form. Begin with patient demographics, then provide PMH, then describe the history

behind why the patient is seeking care. End with any additional pertinent information such as

risk factors, contributory social history, etc.

Hospital Interval: This is applicable when the patient has had more than a one-day stay in the

hospital, demonstrating illness progress or improvement in illness. As well as records pertinent

events during hospitalization. Provide it to follow the HPI as it is an extension of the HPI.

Allergies: State the offending medication/food and the reaction.

Medications: Use list format and include complete dosing information: Name, dosage, and

routes of administration prior to hospitalization. Include compliance.

PMH: Past medical history This should include past illness/diagnosis, conditions, traumas,

hospitalizations, and surgical history. Include dates if possible.

Social history: Related to the problem, education level/literacy, HIV risk, sexual activity, work,

and other stressors as appropriate. Smoking, alcohol, and illicit drug use should be evaluated for

every patient and usage quantified. Quantify Cultural and spiritual beliefs that impact health and

illness. Financial resources.

Family history: Use terms like maternal, paternal, and the diseases and the ages of deceased or

diagnosed if known. Make sure it is pertinent history.

Health Maintenance/Promotion: Immunization, exercise, diet, etc. This should be pertinent to

the chief complaint. Consider the United States Clinical Preventive Service Task Force

(USPSTF) guidelines for age-appropriate indicators.

Review of Systems (ROS): ROS should be comprehensive on H&P, Consultation, and

discharge notes. Make sure to include any pertinent negatives and positives that would help with

your differential diagnosis. For progress note, only a focused ROS is needed; if unable to obtain

ROS, explain why. Highlight abnormal findings in ROS with bold font.

General:

Skin:

HEENT:

Neck:

CV:

Lungs:

GI:

GU:

PV:

MSK:

Neuro:

Endo:

Psych:

Objective (This section includes what others can observe and diagnostics.)

Vital signs: Mark abnormal numerical data with bold font.

Medications: Use list format and include complete dosing information: Name, dosage, and

routes of administration administered during hospitalization. Include indication

Physical examination (PE): Perform either a focused or comprehensive exam. This area should

confirm your findings related to the diagnosis. ALL SOAP NOTES should have a physical

examination of CV and lungs. Your physical exam information should be organized using the

same body system format as the ROS section. Appropriate medical terminology describing the

objective examination is mandatory. Highlight abnormal findings in PE with bold font. While

the list below is provided for your convenience, it is not to be considered all-encompassing, and

you are expected to include other systems/assessments applicable to your patient.

Gen:

Skin:

HEENT:

Neck:

CV:

Lungs:

Abd:

GU:

PV:

MSK:

Neuro: If cranial nerves are examined, do NOT write out Cranial nerves intact but describe

how the cranial nerves were examined.

Psych:

Labs and diagnostic test: Include dates. Highlight abnormal findings with bold font. Include

trends as necessary. Attempt to explain any abnormalities.

For example: K+ 3.0 (low) likely secondary to aggressive diuresis.

For example: Hg 7.5 (low) likely secondary to GIB

Assessment

A differential diagnosis list is not typically found in clinical practice. However, make sure to

document all new or worsening findings utilizing a prioritized differential diagnosis list

Prioritized Diagnoses list will include your actual diagnoses that you are treating. List these in

order from most important to least.

Assessment: Provide assessment based on subjective and objective findings. Discuss diagnoses

and severity and provide medical decision-making to support your evaluation and management

plans. Remember to include pertinent data provided in the subjective and objective areas. This is

not just a repeat of the HPI.

Plan

Numerically organize with the principal problem (diagnosis) first in the problem list (Systems-

based organization is also accepted if preferred by the preceptor in ICU, however, make sure to

list appropriate diagnosis under each system). Plans should include diagnostics, labs (frequency),

therapeutics (Medications with names, dosing, frequency, and routes), Education,

Consultation/Collaboration. Remember to include basic admission orders (diet, ambulation

status, precautions, when provider should be alerted to abnormal), code status, health proxy,

estimated length of stay, anticipated disposition, VTE PPX, and/or GI PPX if applicable. Include

ICD-10 Codes for each diagnosis and E&M Level. Consider use of FAST HUGS BID as a

guide.

References

Reference should support your patients management plan, including evidence-based practice,

and utilize APA formatting.