SOAP Notes [MZ - Jan 19]

S

(This is the subjective section in a SOAP note: please provide each discussed concern as a numbered list only if there is more than 1 item, otherwise use bullet points (each item on a new line, with each point under the numbered list item being a sub-item prefixed with a dash). Do not use the word "reports", simply describe the point. Each numbered list concern should be very brief without details. Details are for the Assessment section. Do not include negatives unless spoken out during encounter. If no other concerns discussed, there is no need to say no other concerns discussed. Do not use medical terminology here unless the patient used them, this should be from the patient's perspective.) [Provide a general overview of the patient's subjective experience, including cognitive assessment results, memory or cognitive function, and any relevant test scores. Discuss observations about variability related to factors such as fatigue. Include follow-up details for any concerns or other health issues, documenting patient history, current concerns, and any pending procedures. List any patient requests for laboratory work or monitoring, specifying tests and any relevant home monitoring practices. Discuss any other relevant subjective information, including patient-reported symptoms, lifestyle factors, or concerns that may impact their health or treatment plan.]

O/E

(This is the Objective section in a SOAP note: please provide each objective/examination as a new line. This section should include objectives measured and reported by the physician only. Only include objectives and exam results verbalized by the physician. If not vitals or exam is performed, ignore mentioning that no exam/vitals performed.) "telephone appointment pt sounded well, NAD detected speaking clearly in full coherent sentences" [Describe the type of appointment (e.g., telephone, in-person) and general patient appearance or condition. Include observations on speech, behavior, and any relevant examination findings, imaging/labs/blood work results. Include results of cognitive assessments (if done) or other relevant tests with current and previous scores if applicable.]

A

(This is the Assessment section in a SOAP note: please provide each assessment as a numbered list only if there is more than 1 item, otherwise use bullet points (each item on a new line) to match the subjective section order of discussed concerns. This section should include assessments reported by the physician only.) [This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.] [Problem] List the problem list in order of importance. [Differential Diagnosis] This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely. [Example: Problem 1, Differential Diagnoses, Discussion. Repeat for additional problems]

P

(This is the Plan section in a SOAP note: please provide each plan as a numbered list only if there is more than 1 item, otherwise use bullet points (each item on a new line) to match the assessment section order of discussed concerns.) [This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:] [State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative Therapy needed (medications) Specialist referral(s) or consults Patient education, counseling]