LIMITED

PRIMARY CARE
SOAP NOTE

SGT – J. Guzman
Obtain subjective information
from a patient
1. Subjective information
a) Obtain a relevant history of the patients presenting symptoms
or chief complaint.
b) Issues you can not necessarily find in an examination. What the
patient reports he feels or understand as the problem.
c) Usually documented in direct quotes from the patient.
2) subjective information collected
a) Age, sex, race and first day of last menstrual period (FDLMP).
b) Chief complaint - have the patient state in one sentence, the
reason for their visit, example ''I twisted my ankle while
running this morning''
c) History of present illness (HPI) - contains all of the relevant
information to the patient's chief complaint .the following are
the characteristics of the chief complaint. its components are

O, P, Q, R, S, T
i. Onset: sudden? Gradual? Specific injury/activity?
ii. Provoking/palliative factors: what makes it worse/better?
iii) Quality: what does the pain feel like? Sharp? Dull?
iv) Region/radiation: where is the pain? Localized to one area?
v) Severity: how would you rate the pain on a scale of 1 to 10?
Does it limit your activity? 10 is the worst pain you have ever
had.
vi) Timing: duration? Is it intermittent? Constant?
d) Past History – contains information that may contribute to
the HPI. This information may be helpful in determining
possible causes of the chief complaint or to rule out other
possible causes. This information may also impact your
treatment decisions.
i. Past medical history (PMH)- list any significant medical
diagnosis or disease condition the patient has, such as
hypertension or diabetes.
ii. Past surgical History (PSH)- list any significant surgical
procedures that may have been performed. Examples:
appendectomy, tonsillectomy, cesarean delivery. Etc.
iii. Social History(Soc Hx)- document the patient's use of
tobacco, alcohol and/or illegal substances. Occupation and
leisure activities may be relevant and would be entered in
this section. Examples: "smokes 1 pack of cigarettes per
day"(1 ppd cigarettes), drinks six 12-oz cans of beer per night.
e) Last oral intake- the last thing the patient had to eat and
drink and when they consumed it.
f) Events leading to the illness or injury- the situation that led to
the illness or injury if known. Examples: I was driving 30 mph
without a seatbelt when my car hit the car that was stopped
in front of me.
3) The principal components are:
a) Onset: Sudden? Gradual? Specific injury or activity?
b) Provoking/Palliative factors: what makes it worse or better?
c) Quality: What does the pain feels like? Sharp? Dull?
d) Radiation/Region: where is the pain? Localize to one area?
e) Severity: How would you score the pain on a scale of 1-10.
f) Timing: Duration? Is the pain intermittent? Constant?
4) Past History- contains information that may contribute to
the HPI. This information may be helpful in determining
possible causes of the chief complaint or to rule out other
possible causes. This information may also impact your
treatment decisions. The principle components are:
a) Signs/symptoms:
b) Allergies
c) Medication
d) Past medical and surgical history including social history.
i. Past medical history (PMH)
ii. Past Surgical History(PSH)
iii. Social History(Soc Hx)
e) Last oral intake
f) Events leading up to illness or injury.
 Obtain Objective
Information from a Patient
1. Objective Information
a) Vital Signs
b) Physical Examination findings
c) Nothing from the patient's comments or history is recorded
here.
2) Objective Information Collected
a) Vital signs:
i. Height
ii. Weight
iii. Pulse
iv. Respiratory rate
v. Blood pressure
vi. Temperature
vii. Oxygen saturation(pulse oximetry reading)
b) General impression (GEN)- this is a statement of your initial
impression of the current state of the patient's general health.
i. GEN-patient in no acute distress(NAD)
ii. GEN-patient appears to be in severe pain.
c) physical examination findings by body area- examine body areas
that are related to the history you obtain under subjective section.
NOTE: Below outlines basic information that should be obtain
by type of body area . This is generalize information. The block of
instruction following this one will go into each area in depth.
i) Orthopedic
1) Inspection- have the patient place one finger on the spot it
hurts to localize the pain. Look for ecchymosis, edema,
atrophy, deformities and posture. Compare affected
extremity to the unaffected one. Observe the pt walk and
analyze gait and arm swing. Does he bear weight on it?
2) Palpation-palpate the affected area for DCAP BTLS,
temperature changes and PMS.
3) Range of Motion(ROM)
4) Muscle strength
5) Special test-How a pt reacts to stretch or stress on a joint and
tissue may make the evaluation more efficient and provide
valuable clues to the diagnosis. There are many special test
for specific anatomic injuries and disorders.
ii) Skin
1) Inspect-general color of the skin, vascularity and evidence of
bleeding or bruising.
2) Palpate-general condition of the skin temperature.
3) Observe any lesion of the skin. Note their anatomical
location, distribution, grouping, type and color.
iii) EENT
1) Inspect and palpate external and internal(where applicable)
structures of the eyes, ears, nose, sinuses, and throat for
DCAP BTLS and foreign bodies.
2) Special Tests
a) Visual acuity and pupillary reaction of the eyes.
b) Gross hearing of the ears
iv) chest(Respiratory)
1) inspect and palpate both the anterior and posterior thorax
for DCAP BTLS
2) note rate, rhythm and effort of breathing.
3) auscultate breath sounds bilaterally.
iv) Abdomen
1) Have the patient point to the painful areas and examine
those areas last.
2) Auscultate- place a stethoscope on each of the four
quadrants for presence of bowel sounds. The peristaltic
action of the bowel produces between 5-34 clicks or gurgles
per minute in each quadrant.
3) Inspect and palpate for DCAP BTLS and TRD
 Complete an assessment
1) Your suspected diagnosis.
2) Document your presumptive diagnosis based on the history
and your physical examination findings.
3) If unsure of a diagnosis, simply restate the patients chief
complaint.

a) Example: A – R knee pain

b) Meaning: assessment – Right knee pain
 Develop a treatment plan
1) This is your treatment plan.
2) Treatment plans may also include:
a) Medication and dosage if prescribed.
b) Duty and activity restriction (exemption) , if any.
c) Special actions if any such as ice/heat, compression,
elevation, splint or crutches.
d) Referral to medical officer.
i. Refer all "red flags"
ii. The entire treatment plan may be as simple as P – refer to
medical officer
e) when the patient should return for follow up evaluation.
i. Every SOAP note should include the circumstances under
which the patient should return.
ii. Example: "return to clinic (RTC) if symptoms persist, worsen
or new symptoms develop"
3) Profiles
a) Unless specifically authorized by the supervising medical
officer SOP, screeners are not authorized to issue exemptions
or bed rest.