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Subjective

What the patient tells you
CC and HPI, pertinent ROS to CC and HPI, Pertinent parts of the rest of history, Meds and allergy

Objective

Height, Weight, BMI, BP, T, P, R, Pain, General (well-developed, well-norished...), physical exam pertinent to the CC, lab/studies (that you have results for)

Assessments

Numbered list of diagnosis, each diagnosis has a status (acute, improving, deteriorating, chronic), working diagnosis (most probable cause of the symptoms), DDX (differential diagnosis) = 3 possible causes, other Co morbid/chronic problems

Plan

what you are going to do. Lab/xray, medications, OMM, patient education, follow-up

Chief Complaints

what the pt tells you in their own words the reason fr their visit. may use quotes.

1st line include

age, ethniticy, gender, significant PMH, CC, duration of CC

what do you write for subjective

This 43 yo Caucasian female with an unremarkable PMH presents for a follow up for cough X 14 days

only "pertinent" info

in Subject part of SOAP

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