SOAP Notes
Chief Complaint:
History of Present Illness (HPI):
Active listening
Discussing the topics with the patient in a way they understand it
Make sure you summarize the chief complain before moving to the next portion of data
gathering
Only ask one question at a time because that would be double-barreled question.
Don’t ask leading questions
OPRST- an example knee pain
Onset – When did it start – when did the knee pain started (3 weeks ago), Have this
ever happen
P- anything makes it better- Does anything make it worst, does walking or running
make it worst. When I rest and elevate my knee it helps with the pain
Q- is the pain sharp or dull- describe the knee pain, it feels like someone stabbing
my knee, its in the middle part of my knee.
R- location0 where does the pain start, and does it radiate to another location – The
pain is only in one spot and doesn’t radiate.
S- 1-10 When the pain started it was a 7 and when I rest my knee the pain got
better
T- looking for a pattern she mentions the pain is worst when she is running
