Posted: September 6th, 2023
Episodic/Focused SOAP Note Template
Episodic/Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Race: African American
Mr. S. is a 34-year-old African American male who presents with a pounding, pressure-type headache that began 3 days ago. The headache is located in the frontal and temporal areas and is associated with nausea, vomiting, photophobia, and phonophobia. The patient reports that the headache is worse after being on the computer all day at work. Light bothers his eyes, and taking Aleve makes the pain tolerable but not completely better. The patient rates the severity of the headache as 7 out of 10.
Immunization status not reported. No significant past medical history.
Mr. S. is a construction worker and denies tobacco and alcohol use. He reports no recent changes in his living environment or cell phone use while driving. He has a supportive family.
No significant illnesses reported in the family.
General: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Denies visual loss, blurred vision, double vision, or yellow sclerae. No hearing loss, sneezing, congestion, runny nose, or sore throat.
Cardiovascular: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
Respiratory: No shortness of breath, cough, or sputum.
Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
Genitourinary: Reports burning on urination. Last menstrual period is unknown.
Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: No muscle, back pain, joint pain, or stiffness.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: No enlarged nodes. No history of splenectomy.
Psychiatric: No history of depression or anxiety.
Endocrine: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
Allergies: No history of asthma, hives, eczema, or rhinitis.
Vital Signs: Blood pressure 120/80 mmHg, pulse 76 bpm, respiratory rate 16 bpm, temperature 98.6°F, oxygen saturation 99% on room air.
General: Appears well-nourished, well-developed and in no acute distress.
Head: Normocephalic, atraumatic, no masses or lesions palpated.
Eyes: PERRLA, EOMI, no scleral icterus, no conjunctival injection, no visual field deficits.
Ears: Tympanic membranes are clear, no erythema or effusion.
Nose: No septal deviation, no mucosal edema, no polyps or masses.
Throat: Oropharynx is clear, no erythema or exudates.
Neck: Supple, no lymphadenopathy or thyromegaly appreciated, no jugular venous distention.
Cardiovascular: Regular rate and rhythm, no murmurs, gallops or rubs, distal pulses intact.
Lungs: Clear to auscultation bilaterally, no wheezing or crackles.
Abdomen: Soft, non-tender, non-distended, no hepatosplenomegaly or masses.
Musculoskeletal: No tenderness or swelling appreciated
Based on the patient’s history and physical exam findings, the most likely diagnosis is migraine headache. The patient’s symptoms, including the location of the headache, associated nausea, vomiting, photophobia, and phonophobia, are all consistent with migraine headaches. The exacerbation of symptoms with prolonged computer use is also a common trigger for migraine headaches.
The patient’s vital signs, physical exam, and review of systems do not reveal any concerning findings that would suggest an alternative diagnosis.
Intracranial mass lesion
Education about migraine headaches and possible triggers, including prolonged computer use, stress, certain foods, and sleep disturbances.
Prescribe abortive therapy with triptans, such as sumatriptan or rizatriptan, for when the patient experiences a migraine headache. Advise the patient to take the medication as soon as possible after the onset of symptoms for the best efficacy.
Recommend a nonsteroidal anti-inflammatory drug, such as naproxen or ibuprofen, as a first-line treatment for mild-to-moderate migraine headaches or as an adjunct to triptans.
Advise the patient to maintain good sleep hygiene, regular exercise, and a healthy diet to minimize the frequency and severity of migraine headaches.
Schedule a follow-up appointment in 2-4 weeks to assess the effectiveness of the treatment plan and make any necessary adjustments.