lOMoARcPSD|17673785
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating:
170 90 kg 142/ 86 19 101.1 99% Medication: Penicillin- Rash/ hives
cm 82 F Food: no known allergies
Environment: Cat dander and dust- rhinorrhea, pruritic and periorbital
edema, wheezing
History of Present Illness (HPI)
Chief Complaint (CC) “I got this scrape on my foot a while ago, and I thought it would heal up on its CC is a BRIEF statement identifying
own, but now it's looking pretty nasty, and the pain is killing me!” why the patient is here - in the patient’s
Onset Patient reports initial injury occurred 1 week ago own words - for instance "headache",
Location Wound is on the plantar surface of her right foot NOT "bad headache for 3 days”.
Duration Injury occurred 1 week ago with worsening signs and symptoms in the past 2 Sometimes a patient has more than one
days complaint. For example: If the patient
Characteristics Constant, throbbing, sharp pain with redness, heat, swelling around the foot, presents with cough and sore throat,
worsening in the past 2 days producing a purulent discharge. identify which is the CC and which
Aggravating Factors Walking, standing at work for long periods of time may be an associated symptom
Relieving Factors Resting, elevation, and pain medication
Treatment Tramadol PRN for the pain, cleaning the wound 2 times a day with hydrogen
peroxide and Neosporin with bandage changes 2 times a day
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Tramadol 50 mg 2 tablets 3 times a day as 1 week Foot Pain
needed
Albuterol 90 mcg/spray MDI 1-3 puffs every 4 hours as Since age 2.5 Wheezing/ asthma exacerbation
needed
Neosporin 1 application 2 times a day as needed As needed for 1 Infected wound
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, lOMoARcPSD|17673785
week
Metformin Unknown 1 tablet twice a day Taken 3 years Diabetes
ago
Ibuprofen 600 mg 1 tablet as needed Occasional
Menstrual Cramps
Acetaminophen 500 mg 1 tablet 3 times a day as Occasional
Headaches
needed
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Patient reports that her preexisting medical conditions are type 2 diabetes and asthma. Patient was diagnosed with diabetes when she was 24, reports
staying away from sweets and drinking diet soda instead of regular soda to manage her diabetes. Patient reports that she does not currently take
medication to manage her diabetes but used to take Metformin three years ago. Patient reports infrequent blood glucose monitoring, with her last
glucose check being a week ago in the emergency department. Patient reports being diagnosed with asthma when she was 2.5 years old, with her last
asthma attack being in high school, and last exacerbation being 3 days ago. Patient reports her last hospitalization was 7 days ago to get an x-ray of
her ankle and foot, and prior to that she was hospitalized for asthma when she was 16, with 5 total hospitalizations for asthma as a child and teen.
Patient manages asthma with albuterol inhaler and uses it no more than 2 times per week. Patient reports asthma triggers are caused by cats, dust, and
running upstairs. Patient reports recent unintentional weight loss of 10 pounds that occurred over the past month. Patient denies past diagnosis of
hypertension, and reports that the last BP reading was 140 over 80 or 90 and denies checking her BP regularly. Patient reports being up to date on
general and childhood immunizations with her last tetanus vaccination within the past year, patient denies receiving the flu vaccine annually. Patient
denies any past surgeries.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Patient denies finances and transportation are a barrier to healthcare. Patient reports that she stopped taking Metformin to manage her diabetes
because she disliked checking her blood glucose, the side effects of the medication, and the demands of medication compliance, but denies that cost
of the medication was the reason for discontinuing the medication. Patient reports that she is currently working toward and undergraduate degree in
accounting. Patient reports that she is a supervisor at Mid-American Copy & Ship and has been working at since high school. Patient denies smoking
tobacco. Patient reports that she moved back home to help pay the bills with her mother and sister after her father died. Patient reports that she is
currently under high stress. Patient denies drinking coffee, but reports drinking up to 4 diet sodas per day. Patient reports history of recreational
marijuana smoking and last smoked at the age of 20 or 21, stopped because a loss of interest and for health reasons. Patient denies smoking tobacco,
vaping, or exposure to secondhand smoke. Patient reports that her last alcoholic drink was 3 weeks ago, reports no more than 2 or 3 alcoholic drinks
in one sitting, and reports drinking alcohol 1-2 nights a week. Patient reports a good family support system and enjoys volunteering at her church.
Patient reports that she is single with her last sexual activity with a male partner being 2 years ago. Patient reports a total number of 3 partners and
Downloaded by peter wahu ()
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating:
170 90 kg 142/ 86 19 101.1 99% Medication: Penicillin- Rash/ hives
cm 82 F Food: no known allergies
Environment: Cat dander and dust- rhinorrhea, pruritic and periorbital
edema, wheezing
History of Present Illness (HPI)
Chief Complaint (CC) “I got this scrape on my foot a while ago, and I thought it would heal up on its CC is a BRIEF statement identifying
own, but now it's looking pretty nasty, and the pain is killing me!” why the patient is here - in the patient’s
Onset Patient reports initial injury occurred 1 week ago own words - for instance "headache",
Location Wound is on the plantar surface of her right foot NOT "bad headache for 3 days”.
Duration Injury occurred 1 week ago with worsening signs and symptoms in the past 2 Sometimes a patient has more than one
days complaint. For example: If the patient
Characteristics Constant, throbbing, sharp pain with redness, heat, swelling around the foot, presents with cough and sore throat,
worsening in the past 2 days producing a purulent discharge. identify which is the CC and which
Aggravating Factors Walking, standing at work for long periods of time may be an associated symptom
Relieving Factors Resting, elevation, and pain medication
Treatment Tramadol PRN for the pain, cleaning the wound 2 times a day with hydrogen
peroxide and Neosporin with bandage changes 2 times a day
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Tramadol 50 mg 2 tablets 3 times a day as 1 week Foot Pain
needed
Albuterol 90 mcg/spray MDI 1-3 puffs every 4 hours as Since age 2.5 Wheezing/ asthma exacerbation
needed
Neosporin 1 application 2 times a day as needed As needed for 1 Infected wound
Downloaded by peter wahu ()
, lOMoARcPSD|17673785
week
Metformin Unknown 1 tablet twice a day Taken 3 years Diabetes
ago
Ibuprofen 600 mg 1 tablet as needed Occasional
Menstrual Cramps
Acetaminophen 500 mg 1 tablet 3 times a day as Occasional
Headaches
needed
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Patient reports that her preexisting medical conditions are type 2 diabetes and asthma. Patient was diagnosed with diabetes when she was 24, reports
staying away from sweets and drinking diet soda instead of regular soda to manage her diabetes. Patient reports that she does not currently take
medication to manage her diabetes but used to take Metformin three years ago. Patient reports infrequent blood glucose monitoring, with her last
glucose check being a week ago in the emergency department. Patient reports being diagnosed with asthma when she was 2.5 years old, with her last
asthma attack being in high school, and last exacerbation being 3 days ago. Patient reports her last hospitalization was 7 days ago to get an x-ray of
her ankle and foot, and prior to that she was hospitalized for asthma when she was 16, with 5 total hospitalizations for asthma as a child and teen.
Patient manages asthma with albuterol inhaler and uses it no more than 2 times per week. Patient reports asthma triggers are caused by cats, dust, and
running upstairs. Patient reports recent unintentional weight loss of 10 pounds that occurred over the past month. Patient denies past diagnosis of
hypertension, and reports that the last BP reading was 140 over 80 or 90 and denies checking her BP regularly. Patient reports being up to date on
general and childhood immunizations with her last tetanus vaccination within the past year, patient denies receiving the flu vaccine annually. Patient
denies any past surgeries.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Patient denies finances and transportation are a barrier to healthcare. Patient reports that she stopped taking Metformin to manage her diabetes
because she disliked checking her blood glucose, the side effects of the medication, and the demands of medication compliance, but denies that cost
of the medication was the reason for discontinuing the medication. Patient reports that she is currently working toward and undergraduate degree in
accounting. Patient reports that she is a supervisor at Mid-American Copy & Ship and has been working at since high school. Patient denies smoking
tobacco. Patient reports that she moved back home to help pay the bills with her mother and sister after her father died. Patient reports that she is
currently under high stress. Patient denies drinking coffee, but reports drinking up to 4 diet sodas per day. Patient reports history of recreational
marijuana smoking and last smoked at the age of 20 or 21, stopped because a loss of interest and for health reasons. Patient denies smoking tobacco,
vaping, or exposure to secondhand smoke. Patient reports that her last alcoholic drink was 3 weeks ago, reports no more than 2 or 3 alcoholic drinks
in one sitting, and reports drinking alcohol 1-2 nights a week. Patient reports a good family support system and enjoys volunteering at her church.
Patient reports that she is single with her last sexual activity with a male partner being 2 years ago. Patient reports a total number of 3 partners and
Downloaded by peter wahu ()
