Write your hpi in paragraph form


Assignment Task:

Problem-Focused SOAP Note Format

Demographic Data

Age and gender (must be HIPAA compliant)

Subjective:

Chief Complaint (CC): A short statement about why they are there

History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for...). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, and Treatment

Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

Family Hx: any history of CA, DM, HTN, MI, CVA? 

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:

Vital Signs

Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

Dx Plan (lab, x-ray)

Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

Pt. Education, including specific medication teaching points

Referral/Follow-up

Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference:

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. Looking for Online Tutoring?

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