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SOAP Notes Format in EMR Florida State （在EMR佛罗里达州立SOAP笔记格式）
SOAP Notes Format in EMR
SOAP stands for Subjective, Objective, Assessment, and Plan
Standard Elements of SOAPnote
Date: 08/01/02
Time:
Provider:
Vital Signs:
Height, Weight, Temp, B/P, Pulse
S: This ___ yr old fe/male presents for ____
History of Present Illness symptoms:
Review Of Symptoms/Systems: (For problem-focused visit, document only pertinent information)
Past Medical History: (For problem-focused visit, document only pertinent information)
Current Medications:
Medication allergies:
Social History: (For problem-focused visit, document only pertinent information)
Family History: ((For problem-focused visit, document only pertinent information)
Genogram: 3 generations with health problems, causes of deaths, etc.
or
History of major health or genetic disorders in family, including early death, spontaneous abortions
or stillbirths.
Social History:
Past Medical History History of Present Illness: Cultural Background:
Hospitalizations: Location: Education Level:
Surgical History: Quality Economic Condition:
TA: Severity: Housing:
Appendectomy: Duration: Number in household:
Hysterectomy: Timing (Onset): Marital Status:
Hernia: Timing (Frequency): Lives with:
Coronary Artery Bypass: Context: Children:
Other:
Chronic Medical
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