Board Certified in Internal Medicine
How to present a SOAP note for outpatient and general medical and surgical ward (excluding ICU):
Patient complaints usually are in their own words.
OPQRST: Onset, Provocation, Quality, Radiation, Severity, and Timing.
Pertinent Social History
Pertinent Medicines (if needed)
Pertinent Physical exam:
- Summary of Subjective and Objective briefly usually in one sentence.
- Differential diagnosis
- Most likely diagnosis
- Treatment plan
- Allied health includes but is not limited to PT, OT, SS, etc.
- Social issues
- Expected length of stay (inpatient only)
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