SOAP Note Format – MUSCULOSKELETAL

CC Pain in lower back. “Tweaked” it while lifting a box. 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: 3 days ago Location: Bilateral lower back. Does not radiate. Duration: 3 days Characteristics: Described as an ache, constant, does not radiate. Pain at its worst when she first injured her back stats 6-7/10. Current pain 5/10. Aggravating Factors: Sitting up. Sitting through classes at school. Relieving Factors: Lying down, Advil PO Treatment: Advil Q5-6hours. Current Medications: Advil 2 caps PO Q4-6 hours PRN, Flovent daily inhaler, Proventil rescue inhaler Allergies: PCN (reaction rash/hives). No food allergies, no sea