Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPEARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSCULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph, please state “your encounter with your patient and your findings ( including subjective and objective data)
Example: “Pt came into our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc.… on examination; I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at the PDF example provided) Include the in-text reference/s as per APA style 7th Edition. Make a paragraph
Differential diagnosis (minimum 4) make a paragraph for each one
PLAN:
Labs and Diagnostic Tests to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Soap Note for Alzheimer’s Disease
A SOAP (Subjective, Objective, Assessment, and Plan) note is a method of documentation employed by healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note. Here’s a simplified example of what a SOAP note for a patient with Alzheimer’s disease might look like:
S (Subjective): Patient is an 80-year-old male with a known history of Alzheimer’s disease. He is brought in by his daughter who reports increased confusion and forgetfulness over the past several weeks. She says that he recently has been losing track of the day and time, and occasionally gets lost in the neighborhood. The patient expresses feelings of frustration and anxiety over his worsening memory.
O (Objective): Vital signs are within normal limits. The patient appears to be well-kept but is quiet and seems to be struggling to follow our conversation. The patient’s Mini-Mental State Examination (MMSE) score is 18, indicating moderate cognitive impairment. Laboratory tests, including complete blood count, renal function, liver function, and electrolyte levels, are all normal.
A (Assessment): The patient’s Alzheimer’s disease appears to be progressing given the reported increase in confusion, disorientation, and memory problems. The patient’s MMSE score also supports the progression of cognitive impairment. No acute illness is identified to explain the cognitive changes.
P (Plan):
- Maintain current Alzheimer’s medication regimen and monitor for effectiveness and side effects.
- Recommend increasing home care services for supervision and support, to ensure the patient’s safety.
- Recommend that the patient and his daughter attend Alzheimer’s disease education and support groups to better understand the disease and its progression, and to discuss coping strategies.
- Schedule a follow-up visit in three months or sooner if the patient’s condition worsens.
- Consider consultation with a neurologist or geriatrician if the patient’s cognitive decline continues to accelerate.
Please remember this is a simplified example. Each SOAP note would be individualized based on the patient’s specific circumstances and needs. For a real patient, much more detail would likely be needed.
