Episodic/Focused SOAP Note
Template Patient
Information:
EG, 38, Female.
S.
CC – Contraceptive options
HPI: Elaine Goodwin is a 38-year-old G1 P1 LC 1 presenting to your clinic today to discuss
contraceptive options. She states that she is not interested in having more children, but her
new partner has never fathered a child. She reports that she has used birth control pills before,
but she kept messing them up.
Current Medications: Lamictal and Trileptal
Allergies: No known drug allergy.
PMHx: Exercise-induced asthma,
Seizure disorder (last seizure five years ago)
Soc & Substance Hx:
Denies alcohol use
Denies the use of tobacco products
Denies the use of recreational drug .
Fam Hx:
Maternal grandmother: Alive with dementia
Maternal grandfather: Alive with COPD
Paternal grandparents: Both died in a motor vehicle accident
Mother: Alive with osteopenia and fibromyalgia
Father: Alive, has a history of basal cell
carcinoma Sister: Healthy
Brother: Healthy
Surgical Hx: Tonsillectomy as a child
Mental Hx: No current nor history of mental illnesses reported
Violence Hx: No Current or previous incidences of violence or any form of abuse reported.
Reproductive Hx: G1 P1 LC 1. She has had three different sexual partners in the last year. She
has had the last one for two months and thinks that he is her soul mate. She gets regular
menstrual cycles of 28-32 days for 5-8 days, and on her heaviest day, she must use a super
tampon every hour and get up to change her pad 2-3 times at night. No current contraceptive
use; however, she has used birth control pills before.
, ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue reported.
HEENT: Eyes: No report of visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No report of hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort reported.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No report of anorexia, nausea, vomiting, or diarrhea.
GENITOURINARY: No dysuria, urinary frequency, or urgency reported. Pregnancy. LMP:
not reported
NEUROLOGICAL: Has a history of seizures, last seizure activity five years ago on Lamictal
and Trileptal.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness reported.
Template Patient
Information:
EG, 38, Female.
S.
CC – Contraceptive options
HPI: Elaine Goodwin is a 38-year-old G1 P1 LC 1 presenting to your clinic today to discuss
contraceptive options. She states that she is not interested in having more children, but her
new partner has never fathered a child. She reports that she has used birth control pills before,
but she kept messing them up.
Current Medications: Lamictal and Trileptal
Allergies: No known drug allergy.
PMHx: Exercise-induced asthma,
Seizure disorder (last seizure five years ago)
Soc & Substance Hx:
Denies alcohol use
Denies the use of tobacco products
Denies the use of recreational drug .
Fam Hx:
Maternal grandmother: Alive with dementia
Maternal grandfather: Alive with COPD
Paternal grandparents: Both died in a motor vehicle accident
Mother: Alive with osteopenia and fibromyalgia
Father: Alive, has a history of basal cell
carcinoma Sister: Healthy
Brother: Healthy
Surgical Hx: Tonsillectomy as a child
Mental Hx: No current nor history of mental illnesses reported
Violence Hx: No Current or previous incidences of violence or any form of abuse reported.
Reproductive Hx: G1 P1 LC 1. She has had three different sexual partners in the last year. She
has had the last one for two months and thinks that he is her soul mate. She gets regular
menstrual cycles of 28-32 days for 5-8 days, and on her heaviest day, she must use a super
tampon every hour and get up to change her pad 2-3 times at night. No current contraceptive
use; however, she has used birth control pills before.
, ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue reported.
HEENT: Eyes: No report of visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No report of hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort reported.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No report of anorexia, nausea, vomiting, or diarrhea.
GENITOURINARY: No dysuria, urinary frequency, or urgency reported. Pregnancy. LMP:
not reported
NEUROLOGICAL: Has a history of seizures, last seizure activity five years ago on Lamictal
and Trileptal.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness reported.
