Problem-Focused SOAP Note Format

Demographic Data 

• Age and gender (must be HIPAA compliant) 

Subjective 

• Chief Complaint (CC): A short statement about why they are there 
• History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment 
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance 
• Family Hx: any history of CA, DM, HTN, MI, CVA?  
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. 
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) 

Objective 

• Vital Signs 
• Physical findings listed by body systems, not paragraph form- Highlight abnormal findings 

Assessment (the diagnosis) 

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each 
• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation 

Plan 

• Dx Plan (lab, x-ray) 
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) 
• Pt. Education, including specific medication teaching points 
• Referral/Follow-up 
• Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due 

Reference 

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. 

Liver injury labs are as follows ammonia levels, INR, fibrinogen, glucose, and lactate. Other abs include Alanine transaminase (ALT): 0 to 55 units per liter (U/L) Aspartate transaminase (AST): 0 to 48 U/L. Alkaline phosphatase (ALP): 30 to 129 U/L. Gamma-glutamyltransferase (GGT): 8 to 61 U/L. Bilirubin: 0.1 to 1.2 milligrams per deciliter (mg/dL). Prothrombin time (PT): 10.9 to 12.5 seconds. Albumin: 3.5 to 5.0 grams per deciliter (g/dL). Total proteins: 6.3 to 7.9 g/dL. Once diagnosed liver injury the medications can be adjusted based on the lab results. Also discontinuing of any acetaminophen orders also any other nephrotoxic medications will also be recommended (2022). rising burden of liver disease is mainly a reflection of the three the most common causes: alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis, although autoimmune liver disease is also a significant contributor.4 The burden of liver disease in children differs from that in adults, as although non-alcoholic fatty liver disease (NAFLD) is seen in all ages, reflecting the rise in childhood obesity, disease associated with injecting drug use and alcohol are rarely encountered (Newsome et al., 2018). Acute hepatitis A virus (HAV) infection highly contagious. People who get hepatitis A may feel sick for a few weeks or several months but usually recover completely and do not have lasting liver damage. In rare cases, hepatitis A can cause liver failure and even death. This is more common in older people and in people with other serious health issues, such as chronic liver disease (2022).

           Hepatitis A virus (HAV) is one of the well-known viruses that cause hepatitis all around the globe. Although this illness has decreased in developed countries due to extensive immunization, numerous developing and under-developed countries are struggling with this virus, HAV can be contained and prevented with vaccination. HAV can spread through oral fecal contact and through contaminated foods and water. Acute viral hepatitis is a systemic illness that mainly affects the liver. Hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis D virus (HDV), and hepatitis E virus (HEV) are the viruses that cause almost all instances of acute viral hepatitis, Hepatitis can be present with little or no symptoms, although it frequently results in jaundice, anorexia, and malaise. Hepatitis infection is divided into two types: acute and chronic. Acute hepatitis remains for less than six months, whereas chronic hepatitis stays for an extended period (Torre et al, 2021). In conclusion, vaccination is key to control the spreading of the virus not only for HAV but for all other hepatitis viruses. Immunization has to be considered an important step, and this system will enable the early detection of epidemiologic transitions and the implementation of preventative efforts before HAV infection becomes a public health issue.

References

Newsome, P. N., Cramb, R., Davison, S. M., Dillon, J. F., Foulerton, M., Godfrey, E. M., Hall, R., Harrower, U., Hudson, M., Langford, A., Mackie, A., Mitchell-Thain, R., Sennett, K., Sheron, N. C., Verne, J., Walmsley, M., & Yeoman, A. (2018, January). Guidelines on the management of abnormal liver blood tests. Gut. https://pmc.ncbi.nlm.nih.gov/articles/PMC5754852/

https://my.clevelandclinic.org/health/diagnostics/17662-liver-function-tests. Liver Function Tests. (2022, November 9).

Hepatitis A basics | hepatitis A | CDC. (2025a, January 31). https://www.cdc.gov/hepatitis-a/about/index.html

Gholizadeh, O., Akbarzadeh, S., Ghazanfari Hashemi, M., Gholami, M., Amini, P., Yekanipour, Z., Tabatabaie, R., Yasamineh, S., Hosseini, P., & Poortahmasebi, V. (2023). Hepatitis A: Viral Structure, Classification, Life Cycle, Clinical Symptoms, Diagnosis Error, and Vaccination. The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale, 2023, 4263309. https://doi.org/10.1155/2023/4263309

Torre P., Aglitti A., Masarone M., Persico M., (2021) Viral hepatitis: milestones, unresolved issues, and future goals. World Journal of Gastroenterology.;27(28):4603–4638. doi: 10.3748/wjg. v27.i28.4603

Appropriate Blood Tests for Suspected Acute Liver Injury

     The liver plays a crucial role in maintaining homeostasis, and when acute injury occurs, a thorough evaluation is necessary to determine the extent of damage and underlying cause. Blood tests are essential in assessing liver function, hepatocellular integrity, and potential viral infections. The primary tests ordered for suspected acute liver injury include liver function tests (LFTs), coagulation studies, and viral serologies. Liver function tests provide insight into hepatocyte integrity and bile excretion. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are key markers of hepatocellular damage, often rising significantly in acute injury. In cases of acute hepatitis A virus (HAV) infection, ALT levels can exceed 1000 U/L, with AST also elevated but typically lower than ALT. Alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) assess biliary function, with ALP being mildly elevated in HAV cases. Additionally, total and direct bilirubin levels are crucial in evaluating bile processing and excretion, often presenting as hyperbilirubinemia in acute HAV, which correlates with jaundice. Albumin levels, while generally normal in acute liver injury, may decrease in severe hepatic dysfunction.

      Coagulation studies, including prothrombin time (PT) and international normalized ratio (INR), assess the liver’s synthetic function. Since the liver produces clotting factors, significant hepatic impairment can prolong PT/INR, indicating a decline in liver function. In mild cases of HAV, coagulation parameters remain normal, but in severe cases, PT may be prolonged. To confirm HAV infection, viral serologies are essential. The presence of HAV IgM antibodies indicates a recent or active infection, differentiating it from past exposure or vaccination. HAV IgG antibodies, on the other hand, suggest immunity from prior infection or immunization. The hallmark laboratory findings in acute HAV include markedly elevated ALT and AST, mild increases in ALP, hyperbilirubinemia, and a positive HAV IgM test, confirming acute infection.

References

Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2022). Harrison’s Principles of Internal Medicine (21st ed.). McGraw-Hill Education.

Lee, W. M. (2020). Acute liver failure. The New England Journal of Medicine, 382(22), 2137-2145. https://doi.org/10.1056/NEJMra1917038

Schuppan, D., & Afdhal, N. H. (2021). Liver cirrhosis. The Lancet, 398(10308), 1359-1371. https://doi.org/10.1016/S0140-6736(21)01374-X