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EMR: SOAP Notes Format Cheat Sheet by

Standard Elements of SOAPnote
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S: Subjective

This ___ yr old (fe)male presents for ______­___­___­___­___­___­___­_______
History of Present Illness symptoms: ______­___­___­___­___­___­___­_____
Review Of Sympto­ms/­Sys­tems: (For proble­m-f­ocused visit, document only pertinent inform­ation)

Past Medical History: (For proble­m-f­ocused visit, document only pertinent info)
Current Medica­tio­ns:
Medi­cation allerg­ies:
Social History: (For proble­m-f­ocused visit, document only pertinent info)
Family History: ((For proble­m-f­ocused visit, document only pertinent inform­ation)
Geno­gram: 3 genera­tions wi/health problems, causes of deaths, etc.
or History of major health or genetic disorders in family, including early death, sponta­neous abortions or stillb­irths.
SOAP stands for Subjec­tive, Objective, Assess­ment, and Plan

Past Medical History

Hosp­ita­liz­ati­ons:
Surgical History:
T&A:
Appendectomy:
Hysterectomy:
Hernia:
Coronary Artery Bypass:
Other:
Chronic Medical Proble­ms:
Hypertension
Diabetes
Coronary Heart Disease
Cerebrovascular Disease
Asthma or other COPD
Arthritis
Gout
Renal Disease
Thyroid Disease
Other:
Psyc­hiatric History:
Depression
Anxiety
Substance Abuse
Other:
Immu­niz­ati­ons:
Polio
Tetanus
Last PPD
Cholera
Chil­dhood Illnes­ses:
Tran­sfu­sio­ns:
Alle­rgi­es:

History of Present Illness

Location:
Quality
Severity:
Duration:
Timing (Onset):
Timing (Frequ­ency):
Context:
Relieved by:
Worsened by:
Associated signs and symptoms:
 

Review Of Symptoms (Systems)

Constitutional:
Eyes:
Ears, Nose, Mouth, Throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Skin and/or breasts:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:

Social History

Cultural Backgr­ound:
Education Level:
Economic Condition:
Housing:
Number in household:
Marital Status:
Lives with:
Children:
Occupation:
Occupational Health
Hazards:
Nutrition:
Exercise:
Tobacco use:
Caffeine:
Sexual activity:
Contraception:
Alcohol/recreational drug use:

Family History of

Cancer:
Hypertension:
Hyperlipidemia:
Diabetes Type II:
Coronary Artery Disease:
Stroke:
Alzheimer's:
Depression:
Osteoporosis:
Domestic violence:

O: Observ­ation

Part
Deta­ils
Gene­ral
Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without diffic­ulty.
Skin
Good turgor, no rash, unusual bruising or prominent lesions
Hair
Normal texture and distri­bution.
HEENT
Head: Normoc­eph­alic, atraum­atic, no visible or palpable masses, depres­sions, or scaring.
 
Eyes: Visual acuity intact, conjun­ctiva clea r, sclera non-ic­teric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorr­hages
 
Ears: EACs clear, TMs transl­ucent & mobile, ossicles nl appear­ance, hearing intact.
 
Nose: No external lesions, mucosa non-in­flamed, septum and turbinates normal
 
Mouth: Mucous membranes moist, no mucosal lesions.
 
Teet­h/G­ums: No obvious caries or period­ontal disease. No gingival inflam­mation or signif­icant resorption
 
Phar­ynx: Mucosa non-in­flamed, no tonsillar hypert­rophy or exudate
 
Neck: Supple, without lesions, bruits, or adenop­athy, thyroid non-en­larged and non-tender
Heart
No cardio­megaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs
Clear to auscul­tation and percussion
Abdo­men
Bowel sounds normal, no tender­ness, organo­megaly, masses, or hernia
Back
Spine normal without deformity or tender­ness, no CVA tenderness
Rectal
Normal sphincter tone, no hemorr­hoids or masses palpable
Extr­emi­ties
No amputa­tions or deform­ities, cyanosis , edema or varico­sities, peripheral pulses intact
Musc­ulo­ske­letal
Normal gait and station. No misalign ment, asymmetry, crepit­ation, defects, tender­ness, masses, effusions, decreased range of motion, instab­ility, atrophy or abnormal strength or tone in the head, neck, sp ine, ribs, pelvis or extrem­ities.
Neur­olo­gic
CN 2-12 normal. Sensation to pain, touc h, and propri­oce­ption normal. DTRs normal in upper and lower extrem­ities. No pathologic reflexes.
Psyc­hia­tric
Oriented X3, intact recent and remote memory, judgment and insight, normal mood and affect.
Pelvic
Vagina & cervix without lesions or disc harge. Uterus and adne xa/par­ametria nontender without masses.
Breast
No nipple abnorm­ality, dominant masses, tenderness to palpation, axillary or suprac­lav­icular adenop­athy.
G/U
Penis circum­cised without lesions, urethral meatus normal location without discharge, testes and epidid­ymides normal size without masses, scrotum without lesions.
Nails
Normal color, no deform­ities

A: Assessment

{{fa-square=o}}Assessment: Includes health status and need for lifestyle changes.

{{fa-square=o}}Diagnosis and differ­ential diagnosis:

P: Plan

Laboratory:
X-Rays:
Medications:
Patient Education:
Other:
Follow-up:

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