Contraception SOAP Note (Coursework Sample)

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SOAP Note Assignment Instructions

Consider constructing a Word document ‘SOAP note template’ and use it to assemble your
note. By doing this you can use the template for efficiently constructing your SOAP notes such
that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty
person requests to see your SOAP note template you will be required to send it to them for
review.
All sections of the SOAP note should be addressed relevant to the presenting chief complaint.
Subjective (S):
CC: chief complaint - What are they being seen for? This is the reason that the patient sought
care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness - use the “OLDCART” approach for collecting data and
documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH: past medical history - This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact
health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.
Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet,
etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF)
guidelines for age appropriate indicators. This should reflect what the patient is presently doing
regarding the guidelines.
ROS: review of systems - [Refer to your course modules and the Bickley Etext (Bates Guide) as a
guide when conducting your ROS to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history
of present illness.]
You would also want to include any pertinent negatives or positives that would help with your
differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.)
you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is