THE SOAP TEMPLATE

Hypertension

SOAP: Hypertension (Follow-up visit)

Problem List:

Medication List:

Subjective:

ID

Symptoms

Cardiovascular ROS

Neurological ROS

If symptoms are present:

Location

Timing

Duration

Severity and quality

Modifying factors

Contributing factors

Risk factors

Exposures

Therapy:

Medication

Review of medication

Adverse drug reactions

Patient perceived

Review of anticipated ADRs specific to drug

OTC medications

Herbal supplements and vitamins

Compliance questions (not assessment, history per patient)

Self-monitoring

Medication

Lifestyle

Confounding factors:

Risk factors: diabetes, FH early CHD, hyperlipidemia, smoker, existing CHD

Objective:

Vital signs

Cardiovascular:

JVD

Cardiac exam

Auscultation

PMI

Bruits

Carotid

Abdominal

Pulses

Edema

Lung exam

Neurological, if indicated by history

Reports of labs as indicated based on last assessment  

Electrolytes

UA

Other as indicated

EKG, if indicated

Assessment:

Hypertension

Controlled

Uncontrolled

Comments related to assessment, if indicated (example, uncontrolled.....why)

Plan:

1. Therapy
1. Medication data per general format (dosage, frequency)
2. Counseling re: lifestyle modification
3. Other interventions
2. Monitoring plans
1. Labs
2. Tests
3. BP surveillance
3. Referrals or consultations, if indicated
4. Follow-up schedule
5. Patient education