Western Governors University SOAP Note Subjective Data Case Study

Patient Write-Up

Use the provided template and write up an interesting patient that you have seen in your clinic setting.

The written History and Physical (H&P) serves several purposes:

1. It is an important reference document that provides concise information about a patient’s history and exam findings at the time of the patient appointment.
2. It outlines a plan for addressing the issues that prompted the clinic appointment. This information should be presented in a logical fashion that prominently features all of the data that is immediately relevant to the patient’s condition.
3. It is a means of communicating information to all providers who are involved in the care of a particular patient.

Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced providers.

Written assignment: Use the provided template and write up an interesting patient that you have seen in your clinic setting.

The core aspects of the H&P are described in detail below.

• Chief Concern (CC):
  • One sentence that covers the dominant reason(s) for the visit. While this has traditionally been referred to as the Chief Complaint.
• History of Present Illness (HPI):
  • The HPI should provide enough information to clearly understand the symptoms and events that lead to the patient appointment.
  • A commonly used mnemonic to explore the core elements of the chief concerns is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, and Significance.
  • The remainder of the HPI is dedicated to the further description of the presenting concern. As the storyteller, you are expected to put your own spin on the write-up. That is, the history is written with some bias. You will be directing the reader towards what you feel is/are the likely diagnoses by virtue of the way in which you tell the tale. If, for example, you believe that the patient’s chest pain is of cardiac origin, you will highlight features that support this notion (e.g., chest pressure with activity, relieved with nitroglycerin, preponderance of coronary risk factors etc.). These comments are referred to as “pertinent positives.” These details are factual and no important features have been omitted. The reader retains the ability to provide an alternative interpretation of the data if he/she wishes. A brief review of systems related to the current complaint is generally noted at the end of the HPI. This highlights “pertinent negatives” (i.e., symptoms that the patient does not have). If present, these symptoms might lead the reader to entertain alternative diagnoses. Their absence, then, lends support to the candidate diagnosis suggested in the HPI. Occasionally, patients will present with two (or more) major, truly unrelated problems. When dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the HPI. If so, present them as separate HPIs, each with its own paragraph.
• Past Medical History (PMH):
  • This includes any illness (past or present) that the patient is known to have, ideally supported by objective data. Items that were noted in the HPI (e.g., the cardiac catheterization history mentioned previously) do not have to be re-stated. You may simply write “See above” in reference to these details. All other historical information should be listed. Important childhood illnesses and hospitalizations are also noted.
  • Detailed descriptions are generally not required. If, for example, the patient has hypertension, it is acceptable to simply write “HTN” without providing an in-depth report of this problem (e.g., duration, all meds, etc.). Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension.
  • Also, get in the habit of looking for the data that supports each diagnosis that the patient is reported to have. It is not uncommon for misinformation to be perpetuated when past write-ups or notes are used as the template for new H&Ps. When this occurs, a patient may be tagged with (and perhaps even treated for) an illness which they do not have! For example, many patients are noted to have Chronic Obstructive Pulmonary Disease (COPD). This is, in fact, a rather common diagnosis, but one that can only be made on the basis of Pulmonary Function Tests (PFTs). While a Chest X-Ray and smoking history offer important supporting data, they are not diagnostic. Thus, “COPD” can repeatedly appear under a patient’s PMH on the basis of undifferentiated shortness of breath coupled with a suggestive CXR and known smoking history, despite the fact that they have never had PFTs. So, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.
• Past Surgical History (PSH):
  • All past surgeries should be listed, along with the rough date when they occurred. Include any major traumas as well.
• Medications (MEDS):
  • Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage, frequency, and adherence should be noted.
• Allergies/Reactions (All/RXNs):
  • Identify the specific reaction that occurred with each medication.
• Social History (SH):
  • This is a broad category which includes:
  • Alcohol Intake: Specify the type, quantity, frequency, and duration.
  • Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. When multiplied this is referred to as “pack years.” If they have quit, make note of when this happened.
  • Other Drug Use: Specify type, frequency, and duration.
  • Marital/Relationship Status; Intimate Partner Violence (IPV) screen.
  • Sexual History, including: types of activity, history of STIs.
  • Work History: type, duration, exposures.
  • Other: travel, pets, hobbies.
  • Health care maintenance: age and sex appropriate cancer screens, vaccinations.
  • Military history, in particular if working at a VA hospital.
• Family History (FH):
  • This should focus on illnesses within the patient’s immediate family. In particular, identifying cancer, vascular disease or other potentially heritable diseases among first-degree relatives.
• Obstetrical History (where appropriate):
  • Include the number of pregnancies, live births, duration of pregnancies, complications. As appropriate, spontaneous and/or therapeutic abortions. Birth control (if appropriate).
• Review of Systems (ROS):
  • As mentioned previously, many of the most important ROS questions (i.e., pertinent positives and negatives related to the chief concern) are generally noted at the end of the HPI. The responses to a more extensive review, covering all organ systems, are placed in the “ROS” area of the write-up. In actual practice, most physicians do not document an inclusive ROS. The ROS questions, however, are the same ones that are used to unravel the cause of a patient’s chief concern. Thus, early in training, it is a good idea to practice asking all of these questions so that you will be better able to use them for obtaining historical information when interviewing future patients. A comprehensive list can be found here:
    • Physical Exam:
      Generally begins with a one-sentence description of the patient’s appearance.
      Vital Signs:
      HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, thyroid.
      Lymph Nodes:
      Lungs:
      Cardiovascular:
      Abdomen:
      Rectal (as indicated):
      Genitalia/Pelvic:
      Extremities, Including Pulses:
      Neurologic:
      • Mental Status
      • Cranial Nerves
      • Motor
      • Sensory (light touch, pin prick, vibration and position)
      • Reflexes, Babinski
      • Coordination
      • Observed Ambulation
• Lab Results, Radiologic Studies, EKG Interpretation, Etc.:
• Assessment and Plan:
  • It is worth noting that the above format is meant to provide structure and guidance. There is no gold standard, and there is significant room for variation. When you are exposed to other styles, think about whether the proposed structure (or aspects thereof) is logical and comprehensive. Incorporate those elements that make sense into future write-ups as you work overtime to develop your own style.