SOAP NOTE TEMPLATE (Episodic/Problem Visit)
Student Name:
Date:
Course:
Patient Demographics: (age, gender, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or
OLDCARTS)
Past Childhood Illnesses: measles, mumps, rubella, varicella, scarlet fever, rheumatic fever,
polio, and any other childhood illnesses such as Asthma
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type of reaction/severity/date
Immunization Status: e.g. Flu, COVID, TdaP, etc. Year must be included
Screenings: dental visits, PAP, colorectal screening, microfilament, etc… (Indicate if results
were normal or abnormal)
FMH: pertinent to the CC
Personal History/Social History: Occupation, relationship status, smoking, alcohol, substance
use
Females: LMP and relevant OB/GYN history Gravida, Para, Abortions
Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations,
contraception
Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write class of
medication in parentheses):
For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.
Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic:
Lymphatic:
Endocrine:
Psychiatric:
For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.
Physical Exam:
Vital Signs: Blood Pressure- P- RR- T- Height- Weight- BMIGeneral:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
Breasts:
Lungs:
Heart:
Abdomen:
Genitourinary:
Rectal:
Peripheral Vascular:
Lymphatic:
Extremities: Musculoskeletal:
Neurological:
Pertinent Labs/Diagnostic Testing: Indicate any previous labs or diagnostics done that are
relevant to today’s visit, as well as any Point of Care Testing (POCT) done during the visit
with results.
Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential
diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required
below the table.
Differential
Diagnoses
1.
2.
3.
4.
Pathophysiology
(include APA
citations)
Pertinent Positives
Pertinent Negatives
5.
In a narrative format explain how you arrived at your final diagnosis or working diagnoses based
on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This
should be written using examples of how the history/clinical presentation led to the final
diagnosis or working diagnosis (APA citations to your references must be included – use
resources with Evidence Based Guidelines)
Assessment/Plan:
Include a brief summary of the visit here
(APA citations required in your plan)
List diagnoses applicable to your patient encounter. Diagnosis #1 is your primary/working
diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the
ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be
followed by a plan of care that is evidenced based.
Diagnosis # 1 ICD-10 (must be related to CC/HPI)
a. Plan listed here (plan should be evidenced based, if not, state why the plan deviated
from the evidence)
b.
c.
Diagnosis # 2 ICD-10 may be a chronic condition which is being followed-up (e.g. Asthma,
diabetes)
a. Plan listed here
b.
c.
Diagnosis # 3 ICD-10 may be a chronic condition which is being followed-up (e.g. HTN,
Asthma)
a. Plan listed here
b.
c.
Health Maintenance: Required App for USPSTF screening guidelines
https://epss.ahrq.gov/PDA/index.jsp
Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu
vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—
tobacco cessation program, etc.even though you may not address in an episodic visit)
RTC: (Document disposition)
References (APA Format)