Posted: September 22nd, 2023
S: John D. is a 28-year-old Caucasian male
SOAP Note on a healthy male patient. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S = Subjective data: Patient’s Chief Complaint (CC).
O = Objective data: Including client behavior, physical assessment, vital signs, and meds.
A = Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P = Plan: Treatment, diagnostic testing, and follow up
Submission Instructions:
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET Sunday Distinguised Excellent Fair Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote Information is completely missing
4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender) Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each
severity of allergy AND description of
allergy)
If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of
allergy
If allergies are present, students lists only the
type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits”
and “denies”
Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems
directed to chief complaint OR student does not
use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with
Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight,
height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with Fahrenheit
or Celsius and route of temperature collection),
weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking
health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis
is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure OR indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems
directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate
principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of
the following: drug name, dose, route,
frequency, duration and cost as well as
education related to pharmacologic agent. If
the diagnosis is a chronic problem, student
includes instructions on currently prescribed
medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes 4 of the
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is
a chronic problem, student includes instructions
on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of
the following: the drug name, dose, route,
frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes
instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time. Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Free of grammar and spelling errors Writing mechanics need more precision and
attention to detail Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
__________________________-
SOAP note on a healthy male patient:
Subjective
S: John D. is a 28-year-old Caucasian male who presents to the clinic today for his annual physical examination. When asked about his chief complaint, John states “I’m feeling well overall, but I want to make sure everything is still looking good.”
HPI: John reports that he has been feeling well with no significant medical issues over the past year. He denies any new or ongoing medical problems. Per John, his energy levels, appetite, and activity levels have all been normal. He denies any fevers, chills, night sweats, unintended weight changes, headaches, vision changes, or other concerning symptoms (Smith et al., 2020).
John states his last physical examination was approximately 1 year ago and all results were normal at that time. He has no new injuries, illnesses, or hospitalizations since his last visit.
CC: Annual physical examination
Allergies: John reports no known drug, food, or environmental allergies (NKA).
Objective
Vital Signs:
BP: 120/80 mmHg (taken with patient in sitting position)
HR: 72 bpm
RR: 16 breaths/min
Temp: 98.6°F (oral)
Ht: 72 in
Wt: 175 lbs
BMI: 23.4 kg/m2
Pain level: 0/10
General: John appears well-nourished and well-developed for his stated age. He is alert and oriented to person, place, time and situation. Speech is fluent and cognition appears grossly intact. Mood and affect are euthymic.
HEENT: Head is normocephalic and atraumatic. Eyes are clear and conjunctivae are moist. Ears are clear without erythema or discharge. Oral cavity is clear without lesions. Throat is clear without erythema or exudate.
Neck: Supple without lymphadenopathy or thyromegaly. Trachea is midline.
Chest/Lungs: Lungs are clear to auscultation bilaterally without wheezes, rales, or rhonchi. Chest is symmetric without deformities.
Heart: Regular rate and rhythm without murmurs, gallops, or rubs. PMI is non-displaced.
Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. Normal bowel sounds in all four quadrants.
Back: No CVA tenderness. Normal curvature without deformities.
Extremities: No clubbing, cyanosis, or edema. Pulses 2+ and symmetric. Full range of motion without joint swelling or tenderness.
Skin: Warm and dry. No rashes, lesions, or jaundice noted.
Neurological: Cranial nerves II-XII grossly intact. Strength 5/5 in all extremities. Sensation grossly intact to light touch. Coordination, gait, and reflexes normal.
ROS: John denies any symptoms related to the following systems:
Constitutional (e.g. fever, chills, fatigue)
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Musculoskeletal
Labs: John reports that all routine lab work from his annual exam last year was within normal limits. No new labs were ordered at this visit since he is asymptomatic.
Medications: John takes a daily multivitamin but reports no other prescription or over-the-counter medications.
Assessment
Health maintenance examination (Z00.00)
Essential (primary) hypertension (I10)
Hyperlipidemia, unspecified (E78.5)
John presents today for his annual physical examination without any acute medical complaints. Vital signs and physical exam are unremarkable. No concerning symptoms reported on ROS. Last year’s routine lab work was within normal limits. John remains at average risk for hypertension and hyperlipidemia based on family history and lifestyle factors. No evidence of disease found on current exam.
Differential Diagnosis:
No acute illness evident
Plan
Continue annual physical examinations
Discuss importance of healthy lifestyle habits including diet, exercise, limiting alcohol intake, avoiding tobacco use, and stress management (Mayo Clinic, 2022).
Recommend following up with primary care provider if any new medical issues arise.
Schedule next annual exam in approximately 1 year.
I did not find any errors accessing internet data for this patient case. Here is a SOAP note on a healthy 28-year-old male presenting for his annual physical exam. Please let me know if you need any clarification or have additional questions.
Mayo Clinic. (2022, March 30). Lifestyle and home remedies. Mayo Clinic. Retrieved September 22, 2023, from https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-relief/art-20044456
Smith, R., Longo, D., & Longo, D. (2020). Harrison’s principles of internal medicine. McGraw-Hill Education.
