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Problem-Focused SOAP Note Format
Demographic Data
Patient initial D. T. , age 10 , and gender Male (must be HIPAA compliant).
Subjective
Chief Complaint (CC) Cough, Nasal congestion, Sore Throat
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, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, vaccines)
Objective
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Three (3) differential diagnosis (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
(This is important) – Health maintenance (including when screenings, immunizations, etc., are next due):

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