From the Guidelines
A SOAP note template for a preventative visit should include four key sections: Subjective, Objective, Assessment, and Plan, as this structure ensures comprehensive documentation and maintains a clear record of the patient's current health status and future care needs. When creating a SOAP note for a preventative visit, such as the one for G.H., a 35-year-old woman presenting for a routine preventive visit 1, it's essential to follow this template to ensure all necessary information is captured.
Subjective Section
In the Subjective section, document the patient's chief complaint, reason for visit, health history, family history, social history, and review of systems. Note any preventative care concerns, lifestyle factors, and screening history. For G.H., this would include her admission of not exercising regularly or eating a very healthy diet, as well as her moderate alcohol consumption 1.
Objective Section
The Objective section should include vital signs (blood pressure, heart rate, respiratory rate, temperature, height, weight, BMI), physical examination findings organized by body systems, and results of any point-of-care testing performed during the visit. G.H.'s blood pressure is 110/65 mm Hg, her body mass index is 24.9 kg/m², her total cholesterol level is 170 mg per dL, her low-density lipoprotein cholesterol level is 110 mg per dL, her high-density lipoprotein cholesterol level is 52 mg per dL, and her fasting blood glucose level is 74 mg per dL, as documented in her case study 1.
Assessment Section
For the Assessment section, summarize the patient's overall health status, risk factors identified, and any conditions requiring follow-up or management. Given G.H.'s profile, her risk of cardiovascular disease is low, but it's crucial to discuss her diet and exercise habits further, as suggested by the USPSTF guidelines 1.
Plan Section
Finally, the Plan section should detail preventative recommendations (immunizations, screenings based on age/gender/risk factors), lifestyle modifications, patient education provided, medication adjustments if needed, referrals to specialists, and the follow-up timeline. For G.H., this might involve discussing the benefits of a healthy diet and regular exercise, given the strong correlation among these factors and a lower incidence of cardiovascular disease, even if the health benefit of behavioral counseling is small 1.
Key points to include in the SOAP note for a preventative visit are:
- Comprehensive documentation of the patient's health status and risk factors
- Clear preventative recommendations based on age, gender, and risk factors
- Lifestyle modifications and patient education
- Follow-up timeline for monitoring and managing identified risk factors or conditions.
From the Research
Preventative Visit Soap Note Template
There are no research papers to assist in answering this question directly. However, the provided studies discuss the importance of influenza vaccination in preventing cardiovascular disease and reducing mortality rates.
- The studies 2, 3, 4, 5, 6 focus on the effects of influenza vaccination on patients with cardiovascular disease, but do not provide a template for a soap note for a preventative visit.
- A typical soap note template might include:
- Subjective: Patient's reported symptoms and medical history
- Objective: Vital signs, physical examination results, and laboratory test results
- Assessment: Diagnosis and evaluation of the patient's condition
- Plan: Treatment and prevention strategies, including vaccinations and medications
- For a preventative visit, the soap note might also include:
- Risk factor assessment: Evaluation of the patient's risk factors for cardiovascular disease and other conditions
- Health promotion: Discussion of healthy lifestyle habits and disease prevention strategies
- Screening tests: Results of screening tests, such as blood pressure and lipid profiles
- However, without more specific information, it is not possible to provide a detailed template for a soap note for a preventative visit.