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Posted: November 19th, 2022
PROBLEM-FOCUSED NOTE
36-year-old female G1P1 LMP 10/1/2021
Painful menses each month. No relief with OTC pain medications
Sexually active with 2 male partners. Painful intercourse
Does not use condoms
Severe pain at ovulation
Subjective Data
HPI
Med History – make up answers for her.
Social Hx
Family Hx
Use OLDCART
Include ROS
Objective Data
Include vital signs
Include point of care testing (POCT) (if appropriate)
Include an appropriate exam
Assessment
Include ICD 10 code
Include DDX
Plan
Include medication (if appropriate)
Include education, teaching, follow-up, and referral (if appropriate)
Problem-Focused SOAP Note Format
Demographic data
Patient initial (one initial only), age, and gender must be HIPAA compliant.
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Three (3) differential diagnoses (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
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