Soap Note Format : Patient Information

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SOAP Note Format Patient Information: Initials, Age, Sex, Race, Insurance RC, 35, Male, White, Medical Mutual of Ohio S. Patient states “pain in right leg”. Patient presents with right leg pain and heard a pop. Slipped today while shoveling snow about an hour ago. Rates pain at 6 out of 10 HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: 2 hours ago Location: Right leg Duration: Steady consistent pain Characteristics: Associated with altered gait, edema, limited weight bearing, and range of motion. Aggravating Factors: Applying pressure on the right leg when walking. Relieving Factors: At rest pain decreases to 4 out of 10. Treatment: Wrapped leg in ace bandage. Current Medications: Hydrochlorothiazide 25 mg, orally once a day, for hypertension. Acetaminophen 500 mg, 2 capsules every 6 hours, while symptoms last, for leg pain Allergies: Penicillin, Sulfa PMHx: Last immunization was tetanus on 6/2014 No influenza immunization was taken. Childhood immunization for DTaP, MMR, meningitis, varicella, Hep B, Hib B, OVP, Surgery include tonsillectomy at year 8. Social Hx: Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at

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