Patient Case Sample

Should obtain the following information from the patient chart and/or patient interview:

Chief complaint (at last visit):

HPI:

PMH:

Social History:

Familyhistory:

Allergies:

Present Medications Past Medications (state start and stop date)

Vital signs (date of last scheduled appt)

BP:

Pulse:

Temp:

RR:

Wt:

Ht:

BMI:

PE:

Chart of blood pressures

Date
BP

Chart of blood sugars (if patient has diabetes)

Date
BG

LABS- pertinent to patient’s disease states

Date

Medical Problem list

  1. State most important/uncontrolled problem and list each medical problem in order or urgency in treatment management
  2. Healthcare maintenance (to discuss any screening recommendations needed for this specific patient)

SOAP NOTE

Problem #1- State Problem Here

Findings

  • List all findings (subjective and objective) pertinent to this problem.Don’t include information that is not needed for you to make an assessment or recommendation.
  • Examples:
  • medications the patient is taking that is used for the condition or may aggravate their condition
  • risk factors
  • symptoms patient is describing
  • labs needed to monitor condition or medication patient is taking for the condition

Assessment

  • In 2-4 sentences, make a general assessment of patient’s current problem ( i.e. diagnosis controlled or uncontrolled, iscurrent medication regimen for this condition appropriate or not and why. ).
  • Do NOT repeat findings (it’s already be in the previous section and just makes an unnecessary long note). Do NOT add new information here. All information should be in the Findings section. This section should just be evaluating that information.
  • Include specific goals of therapy for this particular patient.

Plan

  • State first problem
  • List all recommendations you would make for this problem. Include:
  • pharmacologic AND non-pharmacologic recommendations.
  • any counseling specifically to this patient they need with regards to the recommendations you made (no generic recommendations; focus on the patient)
  • future recommendation(s) if current recommendation does not put patient at goal.
  • monitoring needed for patients’ medical condition or medication therapy (ex: major side effects of medication, pertinent lab monitoring needed, what would we look for in terms of efficacy). Please include appropriate parameters needed.

Problem #2- (State 2nd most urgent problem here)

  • follow same format as above

Continue with each medical problem the patient has. Healthcare maintenance should be last medical problem where you can list any necessary lab/screening or vaccinations this specific patient may need that wasn’t listed above.

References:

List the references/resources you used to develop your SOAP note