Episodic/Focused SOAP Note Template
Initials, Age, Gender, and Race
CC (chief complaint) is a SHORT statement that identifies why the patient is here — in the patient’s own words – for example, “headache,” NOT “severe headache for 3 days.”
HPI: This is your note’s symptom analysis section. This section’s documentation is critical for patient care, coding, and billing analysis. Create a mental image of what is wrong with the patient. To finish your HPI, use the LOCATES Mnemonic. Every HPI should begin with age, race, and gender (e.g., 34-year-old AA male). You must mention the seven characteristics of each significant symptom in paragraph style, not a list. If the CC was “headache,” the LOCATES for the HPI may look like this: Example of an Episodic/Focused SOAP Note Template Format Essay
Start date: 3 days ago
Characteristics include pounding and tightness around the eyes and temples.
Associated symptoms include nausea, vomiting, photophobia, and phonophobia.
Timing: after a long day at work on the computer
Exacerbating/relieving factors: light irritates the eyes; Aleve makes it bearable but not alleviated.
Severity: 7/10 on the pain scale
Current Medications: Include the dosage, frequency, length of time utilized, and purpose for the use, as well as OTC or homeopathic drugs.
Allergies: Separately list pharmaceutical, food, and environmental allergies (a description of the allergy, such as angioedema, anaphylaxis, etc.). This will aid in distinguishing between a real reaction and intolerance). Example of an Episodic/Focused SOAP Note Template Format Essay
PMHx: include immunization status (note date of last tetanus shot for all adults), serious illnesses, and surgeries in the past. More information may be required depending on the CC.
Include occupation and significant hobbies, family status, cigarette and alcohol usage (past and present use), and any other relevant data. Always include a health promotion question here, such as if they always wear seat belts or have functional smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: infectious or chronic illnesses with a suspected hereditary tendency. Any deceased first-degree relatives’ cause of death should be included. Parents, grandparents, siblings, and children should all be included. Have grandkids if applicable. Example of an Episodic/Focused SOAP Note Template Format Essay
ROS: include anybody systems that may help you contain or exclude a differential diagnosis. Each system should be listed as follows: General: Head: EENT: and so forth. These should be listed in bullet form, and the systems should be documented from head to toe.
Complete ROS Example:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: No visual loss, blurred vision, double vision, or yellow sclerae in the eyes. Hearing loss, sneezing, congestion, runny nose, or sore throat are not present. Example of an Episodic/Focused SOAP Note Template Format Essay
SKIN: There is no rash or itching.
CARDIOVASCULAR: No chest pain, pressure, or discomfort. There are no palpitations or edema.
RESPIRATORY: No shortness of breath, coughing, or sputum production.
GASTROINTESTINAL: Anorexia, nausea, vomiting, or diarrhea are not present. There is no stomach pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: There are no symptoms of headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. There was no change in bowel or bladder control. Example of an Episodic/Focused SOAP Note Template Format Essay
MUSCULOSKELETAL: No muscular, back, joint, or stiffness pain.
HEMATOLOGY: There is no anemia, bleeding, or bruising.
LYMPHATICS: There are no swollen nodes. There is no history of splenectomy.
PSYCHIATRIC: There has been no history of depression or anxiety.
ENDOCRINOLOGICAL: There have been no reports of excessive perspiration, cold, or heat intolerance. There is no polyuria or polydipsia.
ALLERGIES: There has been no history of asthma, hives, eczema, or rhinitis.
Physical exam: When performing your physical exam, include everything you see, hear, and feel from head to toe. You only need to look at the CC, HPI, and History systems. “WNL” or “normal” should not be used. What you perceive must be described—General: Always document from head to toe, i.e., Head: EENT: and so forth.
Diagnostic results: Include any labs, x-rays, or other diagnostics used to develop the differential diagnoses (support with evidence and guidelines). Example of an Episodic/Focused SOAP Note Template Format Essay
Differential Diagnosess (list a minimum of 3 differential diagnoses).
Your primary or presumptive diagnosis should be at the top of your priority list. Provide supporting documentation and evidence-based guidelines for each diagnosis.
This material is unnecessary for this course’s (NURS 6512) assignments, but it will be required in future courses.
To support your diagnostics and differential diagnoses, you must include at least three evidence-based peer-reviewed journal articles or evidence-based guidelines relevant to this case. Make sure you follow the APA 6th edition formatting guidelines. Example of an Episodic/Focused SOAP Note Template Format Essay