1. Medical Note

2. S
Subjective
Based on subjective things a patient tells a provider (Chief Complaint, HPI) O
Objective
Based on more objective findings of Physical Exam (lab studies, Radiology results) A
Assessment
What does the physician think is going on P
Plan
Where do we go from here

3. Vital Signs HPI Reason For Visit Review of Systems Physical Exam SOAP
NOTE
Assessment/
Plan
Review of Systems
Physical Exam

4. Past, Family, and/or Social History
Past history including experiences with illnesses, operations, injuries, and treatments; Family history including a review of medical events, diseases, and hereditary conditions that may place him or her at risk; and Social history including an age appropriate review of past and current activities.

5. A. Reason For Visit Why is the patient here?
Chief Complaint
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue.

6. History of Present Illness
HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are: (P) Palliative and Provocative factors – What makes it better or worse (walking, rest…) (Q) Quality – What is the pain like (dull, sharp…) (R) Region/Radiation – Where is the pain or symptoms and does it move radiate? (S) Severity – How bad is the problem or pain (mild, severe, excruciating)? (T) Timing – When did it start? Does it persist? What was the patient doing when it started? Is the pain constant or does it come and go? (A) Associated Symptoms – What else comes with the pain (cough, fever, chills)? Other things to include in the HPI: has the patient had this type of pain before and what has the patient attempted prior to arrival (pain med).

7. Sample HPI
Johnny Brown is a 4 month old male who presents with one day of fever associated with a cough productive of dark green sputum. Fever of 104 F at home; mother has been using Tylenol and Ibuprofen to control the fever. Last dose of Ibuprofen given 6 hours ago. Child has been keeping liquids down. Has been urinating normally – 6 wet diapers today. Vaccinations UTD. Mother has an older child with similar symptoms a few days ago. Child does attend daycare. Mom is concerned this could be pneumonia and is requesting antibiotics.

10. B. Review of Systems
ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:
Constitutional Symptoms
HEENT (Head, Eyes, Ears, Nose/sinuses, throat/Mouth)
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal;■■
Reproductive
Metabolic/Endocrine
Neuro/Psychiatric
Dermatologic
Musculoskeletal
Hematologic
Immunologic

12. Constitutional – Weight loss/gain, fever. chills
HEENT (Head, Eyes, Ears, Nose, Mouth, Throat) – Dizziness, lightheadedness, tinnitus, epistaxis, blurred vision
Respiratory - SOB, wheezing, stridor
Cardiovascular - Chest pain, murmurs, edema
Vascular – Cyanosis, edema, Thrombophlebitis
Gastrointestinal – Nausea, vomiting, constipation or diarrhea
Genitourinary – Frequent urination, change in urine color, foul odor
Musculoskeletal – Muscle or joint pain, stiffness, back pain
Reproductive – Pre/post menopausal,
Metabolic/Endocrine – Hair loss, heat intolerance, tremors
Neuro/Psychiatric – Dizziness, headache, loss of consciousness
Dermatologic – Rash, itching, hair or nail problems
Hematologic – Easy bleeding/bruising
Immunologic – Food allergies, asthma

14. C. Physical exam
The next portion of the visit is the Physical exam. During this time the provider is performing the exam and will be calling out findings (normal and abnormal).
General – the patients appears well.
HEENT – pupils equal round, reactive to light
Respiratory – clear to auscultation bilaterally without rales, rhonchi or wheezes.
Cardiovascular – regular rate and rhythm. No gallops, rubs or murmurs
Abdomen – bowel sounds normal
Psychiatric – No apparent auditory or visual hallucinations, no suicidal/homicidal ideations
Skin – exposed skin is unremarkable

17. Assessment/Plan
Where do we go from here? The Assessment/Plan is where the provider determines what they think is going on and what they intend to do to address the issue.
The plan can include ordering tests (labs, radiographs) or placing the patient on a medication.

19. Questions