Medical Note

S Subjective Based on subjective things a patient tells a provider (Chief Complaint, HPI) O Objective Based on more objective findings of Physical Exam (lab studies, Radiology results) A Assessment What does the physician think is going on P Plan Where do we go from here

Vital Signs HPI Reason For Visit Review of Systems Physical Exam SOAP NOTE Assessment/ Plan Review of Systems Physical Exam

Past, Family, and/or Social History Past history including experiences with illnesses, operations, injuries, and treatments; Family history including a review of medical events, diseases, and hereditary conditions that may place him or her at risk; and Social history including an age appropriate review of past and current activities.

A. Reason For Visit Why is the patient here? Chief Complaint A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue.

History of Present Illness HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are: (P) Palliative and Provocative factors – What makes it better or worse (walking, rest…) (Q) Quality – What is the pain like (dull, sharp…) (R) Region/Radiation – Where is the pain or symptoms and does it move radiate? (S) Severity – How bad is the problem or pain (mild, severe, excruciating)? (T) Timing – When did it start? Does it persist? What was the patient doing when it started? Is the pain constant or does it come and go? (A) Associated Symptoms – What else comes with the pain (cough, fever, chills)? Other things to include in the HPI: has the patient had this type of pain before and what has the patient attempted prior to arrival (pain med).

Sample HPI Johnny Brown is a 4 month old male who presents with one day of fever associated with a cough productive of dark green sputum. Fever of 104 F at home; mother has been using Tylenol and Ibuprofen to control the fever. Last dose of Ibuprofen given 6 hours ago. Child has been keeping liquids down. Has been urinating normally – 6 wet diapers today. Vaccinations UTD. Mother has an older child with similar symptoms a few days ago. Child does attend daycare. Mom is concerned this could be pneumonia and is requesting antibiotics.

B. Review of Systems ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized: Constitutional Symptoms HEENT (Head, Eyes, Ears, Nose/sinuses, throat/Mouth) Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal;■■ Reproductive Metabolic/Endocrine Neuro/Psychiatric Dermatologic Musculoskeletal Hematologic Immunologic

Constitutional – Weight loss/gain, fever. chills HEENT (Head, Eyes, Ears, Nose, Mouth, Throat) – Dizziness, lightheadedness, tinnitus, epistaxis, blurred vision Respiratory - SOB, wheezing, stridor Cardiovascular - Chest pain, murmurs, edema Vascular – Cyanosis, edema, Thrombophlebitis Gastrointestinal – Nausea, vomiting, constipation or diarrhea Genitourinary – Frequent urination, change in urine color, foul odor Musculoskeletal – Muscle or joint pain, stiffness, back pain Reproductive – Pre/post menopausal, Metabolic/Endocrine – Hair loss, heat intolerance, tremors Neuro/Psychiatric – Dizziness, headache, loss of consciousness Dermatologic – Rash, itching, hair or nail problems Hematologic – Easy bleeding/bruising Immunologic – Food allergies, asthma

C. Physical exam The next portion of the visit is the Physical exam. During this time the provider is performing the exam and will be calling out findings (normal and abnormal). General – the patients appears well. HEENT – pupils equal round, reactive to light Respiratory – clear to auscultation bilaterally without rales, rhonchi or wheezes. Cardiovascular – regular rate and rhythm. No gallops, rubs or murmurs Abdomen – bowel sounds normal Psychiatric – No apparent auditory or visual hallucinations, no suicidal/homicidal ideations Skin – exposed skin is unremarkable

Assessment/Plan Where do we go from here? The Assessment/Plan is where the provider determines what they think is going on and what they intend to do to address the issue. The plan can include ordering tests (labs, radiographs) or placing the patient on a medication.

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