Posted: January 1st, 2023
Episodic/Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Episodic/Focused SOAP Note Template
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising. Episodic/Focused SOAP Note Template
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Episodic/Focused SOAP Note
Program Name, Institution
COURSE CODE: Course Title
Episodic/Focused SOAP Note
Patient Information: Episodic/Focused SOAP Note Template
S.L, 24, Female, Caucasian
CC (chief complaint): “regular care”
HPI: S.L is a 24-year-old Caucasian female who presents to the clinic for routine checkup. She denies having any medical issues, but does mention occasional cramping throughout her menstrual cycle, which she relieves using Pamprin. She also claims to have had a sore throat for the previous three weeks and some post-coital bleeding for the past six weeks. She had a fever for a few days, but Tylenol brought it under control.
Current Medications: Pamprin for cramps, Tylenol for fever
PMHx: No medical history
Soc& Substance Hx: Patient is an administrative assistant by profession and puts in a full-time shift every day. She also confesses to drinking between six and eight bottles of hard liquor every day, using marijuana, and smoking a half pack of cigarettes every day beginning when she was fourteen years old. She goes for a jog three to four times a week. She mentions using sunscreen once in a while. She observes driver safety procedures, such as wearing her seat belt at all times.
Fam Hx: Non-contributary
Surgical Hx: No surgical history
Reproductive Hx: Menarche at age 13, menstrual cycle is 28 to 32 days and lasts 4 to 6 days. She reports using 3 tampons daily. She gets cramps during her periods and uses OTC Pamprin for relief.
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies eye pain or vision problems. Ears, Nose, Throat: Denies hearing changes, runny nose, congestion. Reports sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.
ENDOCRINOLOGIC: Denies sweating or cold or heat intolerance.
GENITOURINARY/REPRODUCTIVE: Reports menstrual cramping and post-coital bleeding.
General: in no apparent distress.
HEENT: anterior cervical adenopathy bilaterally, erythema in throat
Lungs: clear to auscultation
CV: regular rate and rhythm, no gallop or murmur
Abd: soft, non-tender, liver normal
Breasts: no masses, adenopathy, or discharge. Bilateral nipple piercings
VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
Cervix: friable, some petechia no cervical motion tenderness.
Uterus: mid mobile, non-tender Adnexa: without masses or tenderness
Extremities: full rom, skin clear, no edema, reflexes 1+. Neurological: CN II-12 grossly intact.
Vaginal culture- positive for Chlamydia
Wet mount- many WBCs.
hepC, RPR, HIV negative
Primay and Differential Diagnoses
Chlamydia: Chlamydia is likely the most accurate diagnosis for this patient, in my opinion. According to O’Connell and Ferone (2018), chlamydia is the sexually transmitted infection (STI) that is diagnosed the most worldwide. Some of the symptoms that women may experience include postcoital bleeding, intermittent bleeding, dysuria or polyuria , or alterations in their vaginal discharge. In later stages, patients may have a sore throat and fever. Chlamydia is the most likely diagnosis for this patient given the symptoms they are exhibiting.
Gonorrhea: Neisseria gonorrhoeae is the bacteria that is responsible for causing gonorrhea. This prevalent sexually transmitted infection (STI) often affects parts of the body that are warm and moist. If someone has gonorrhea, they could not have any symptoms at all. Some people could notice a change in their vaginal discharge, while others might have stomach pain, unilateral labial pain or inflammation (Schuiling & Likis, 2020)Episodic/Focused SOAP Note Template.
Trichomoniasis: Trichomoniasis is a common ailment that is spread via sexual contact and is brought on by a parasite. Trichomoniasis may result in an unpleasant-smelling vaginal discharge, irritation in the genital area, and painful urination in females. Trichomoniasis is known to irritate the vaginal region, which may make it simpler for other sexually transmitted infections to enter the body or be passed on to other people (Schumann & Plasner, 2021). Trichomoniasis may potentially increase the risk of HIV infection, the virus that causes AIDS. There is a correlation between having this condition and having an elevated chance of developing cervical cancer in women.
The first step in caring for S.L. is to conduct an exhaustive health history review and gather further information. To begin, I would inquire more about her sexual history by inquiring about the sexual partners she has had, the sexual practices she engages in, the history of STIs she has had, her prospects for pregnancy, and how she protects herself from STIs. In addition, I will place an order for diagnostic testing, which will include a nucleic acid amplification test (NAAT), which will examine urine or swab samples to look for signs of infection. In addition, I would conduct STI screening, a vaginal swab, and a pap smear.
O’Connell, C. M., & Ferone, M. E. (2018). Chlamydia trachomatisGenital Infections. Microbial cell (Graz, Austria), 3(9), 390–403. https://doi.org/10.15698/mic2016.09.525
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
Schumann, J. A., & Plasner, S. (2021). Trichomoniasis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534826/
Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04 • HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened. • Lung: clear to auscultation • CV: regular sinus rhythms without murmur or gallop • Abd: soft, non-tender, liver normal, • Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings. • VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted • Cervix: friable, some petechia no cervical motion tenderness. • Uterus: mid mobile, non-tender • Adnexa: without masses or tenderness • Perineum: wnl • Rectum: wnl • Extremities: full rom, skin clear, no edema, reflexes 1+. • Neurological: CN II-12 grossly intact. Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.) Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations. Episodic/Focused SOAP Note Template
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