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.