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Steps to Writing a SOAP Note
Transcript of Steps to Writing a SOAP Note
Objective: Vitals, Physical Exam
Subjective or Objective???
ALWAYS include Health Maintenance
(immunizations, cancer screenings, smoking cessation).
Weight may also be included in this category.
Anything reported by patient
Review of Systems
Home testing results (unless have meter/monitoring with them)
Meds as reported by patient
Complaints reported by patient
Social history, family history, PMH
Anything you would have to trust the patient with
Items in the wrong section
Missing dose, frequency, medication on medication list
Evidence for problem/guidelines
Goals of therapy
Assessment of changes
What is your assessment of the patient's current status?
NOT what you plan to do, just ASSESS
Systems based physical exam
Vital exams taken by YOU/nurse/doctor
Studies (EKG, x-rays, CT scans, pending tests
Immunizations from patient chart
Information you can verify/have witnessed/assessed during examination or hospital stay
Information can go in both S/O?
BP taken upon arrival
Medication List patient brought
Evidence to support
Recommendations made/conversation with patient