SOAP FLOW DC - soap
, lOMoAR cPSD| 47061011
Subjective
The subjective part of a SOAP note refers to the patient’s chief complaint, history of present
illness, past medical history, and review of systems. The subjective section includes what the
patient reports (aka the subjective information). If the patient is unable to provide details (i.e. a
child or unresponsive patient), the nurse practitioner can ask a caregiver, family member,
bystander, or even other healthcare providers (EMS) for information.
Chief complaint
To start the subjective portion, introduce the patient and their reason for seeking medical
attention (aka chief complaint). For example, “Patient presents with complaints of an ongoing
cough and shortness of breath.”
History of present illness
Then, document the patient’s history of the present illness. This includes how the patient
describes the symptoms, the onset and duration of symptoms, past treatment, etc.
When writing a SOAP note, I like to use the OLDCARTS acronym when describing the history of
present illness.
O- Onset (acute or gradual)
L- Location
D- Duration
C- Characteristics
A- Aggravating factors
R- Relieving factors
T- Treatments (and response)
S- Severity or Symptoms
Utilizing the OLDCARTS acronym helps remind me what questions to ask when obtaining the
history of present illness. It also helps to document information in a systematic way.
Here is an example of a history of present illness, “Patient presents to the clinic for complaints
of right forearm pain. Pain started after the patient slipped on the ice and landed on right
, lOMoAR cPSD| 47061011
Subjective
The subjective part of a SOAP note refers to the patient’s chief complaint, history of present
illness, past medical history, and review of systems. The subjective section includes what the
patient reports (aka the subjective information). If the patient is unable to provide details (i.e. a
child or unresponsive patient), the nurse practitioner can ask a caregiver, family member,
bystander, or even other healthcare providers (EMS) for information.
Chief complaint
To start the subjective portion, introduce the patient and their reason for seeking medical
attention (aka chief complaint). For example, “Patient presents with complaints of an ongoing
cough and shortness of breath.”
History of present illness
Then, document the patient’s history of the present illness. This includes how the patient
describes the symptoms, the onset and duration of symptoms, past treatment, etc.
When writing a SOAP note, I like to use the OLDCARTS acronym when describing the history of
present illness.
O- Onset (acute or gradual)
L- Location
D- Duration
C- Characteristics
A- Aggravating factors
R- Relieving factors
T- Treatments (and response)
S- Severity or Symptoms
Utilizing the OLDCARTS acronym helps remind me what questions to ask when obtaining the
history of present illness. It also helps to document information in a systematic way.
Here is an example of a history of present illness, “Patient presents to the clinic for complaints
of right forearm pain. Pain started after the patient slipped on the ice and landed on right
