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, 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. 

Case Scenario:

Patient Overview: A 45-year-old patient, Jamie, presents with muscle weakness, difficulty walking, numbness in the limbs, and occasional blurred vision. The patient’s symptoms have worsened over the past few months. During the examination, the healthcare provider notices a delayed reflex response in the lower extremities and decreased coordination.
Jamie mentions a family history of neurological disorders, specifically Multiple Sclerosis (MS).

Diagnostic Findings:

• MRI shows demyelination in regions of the central nervous system.
• Electromyography (EMG) results suggest slowed peripheral nerve conduction velocity.
• Blood tests show elevated levels of specific autoantibodies.

Describe the key differences between each type of qualitative and quantitative research. Provide a workplace example in which qualitative and quantitative research has been applied and how it has been used within your organization.

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format.