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. 

homework

For each course, you will be required a reflective discussion on how the course outcomes, the program outcomes, and the DNP Essentials were achieved throughout the course. Please familiarize yourself with each essential. 

Select two essentials and explain how you will be incorporating them into your practicum project as a DNP student. In Addition, select three leadership role-specific competencies from the AONL packet and explain how you will be achieving those during the DNP journey.

Possible project theme:  Determine effectiveness of antineuropathic medication to enhace pain management outcomes in patients with neuropathicc pain over opioids as first-line treatment for lumbar radiculopathy