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SOAP NOTES
SOAP TEMPLATES
NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: T. J.
Age: 28
Gender: Female
Height: 170cm
Weight: 86kg
BMI: 30.8
BP: 140/81
BG: 224
RR: 20
HR: 89
Temp: 98.5
SPO2: 97%
Pain (1-10): Denies
LMP: 1/14/20- irregular; every 2 moths; or 6 times a year
Allergies: YES
Medication: Penicillin- rash/hives
Food: Denies
Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing
and wheezing.
History of Present Illness (HPI)
“It feels like it’s been hard to take in air. My chest feels all tight and I’ve been wheezing. I’ve
had to use my inhaler a lot, and it doesn’t feel like it’s totally working”.
Chief Complaint (CC): Chest tightness inhaler not working
Onset: Intermittent chest tightness the last 2 days after being near cats.
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SOAP NOTES TEMPLATE
Location: Chest and Lungs
Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since
original episode. Waking up twice a night with asthma the past 2 nights.
Characteristics: Shortness of breath not relieve by inhaler prescribed use; Wheezing, inability
to lie flat, dry nonproductive cough; waking at night due to shortness of breath; asthma interferes
with activities of daily life. Chest tightness, not pain.
Aggravating Factors: Exposure to cats or dust; Burst of physical exertions “when hurrying up
or walking upstairs”.
Relieving Factors: Usually inhaler, nothing currently
Treatment: Proventil 90mcg inhaler 3 puffs every 4 hours
Current Medications
Medication Dosage Frequency Length of Reason for Use
Time Used
Proventil 90mcg 3 puffs every 25.5 years Asthma: Wheezing,
4 hours PRN Shortness of breath; Cats
Tylenol Gel 500mg 1 capsule < few weeks Headache
Caps ES PRN ago
Advil 200mg 3 tablets PRN Menstrual Cramps
Three Times
a day
Metformin Unknown 1 tablet BID 1 year age 24 Type 2 Diabetes
Past Medical History (PMHx) –
Asthma: Diagnosed age 2.5 years
Diabetes: Diagnosed age 24 years. Has not taken medications for diabetes for 3 years. Manages
diabetes by avoiding sugar and trying to stay active.
Foot Wound: A few months ago, states it is healing
Hospitalizations: State” A bunch of times as a child for asthma”; last hospitalization was age
16 years.
Chest X-ray age 16 years
X-ray foot few months ago
Surgery: Denies
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SOAP NOTES
SOAP TEMPLATES
NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: T. J.
Age: 28
Gender: Female
Height: 170cm
Weight: 86kg
BMI: 30.8
BP: 140/81
BG: 224
RR: 20
HR: 89
Temp: 98.5
SPO2: 97%
Pain (1-10): Denies
LMP: 1/14/20- irregular; every 2 moths; or 6 times a year
Allergies: YES
Medication: Penicillin- rash/hives
Food: Denies
Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing
and wheezing.
History of Present Illness (HPI)
“It feels like it’s been hard to take in air. My chest feels all tight and I’ve been wheezing. I’ve
had to use my inhaler a lot, and it doesn’t feel like it’s totally working”.
Chief Complaint (CC): Chest tightness inhaler not working
Onset: Intermittent chest tightness the last 2 days after being near cats.
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SOAP NOTES TEMPLATE
Location: Chest and Lungs
Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since
original episode. Waking up twice a night with asthma the past 2 nights.
Characteristics: Shortness of breath not relieve by inhaler prescribed use; Wheezing, inability
to lie flat, dry nonproductive cough; waking at night due to shortness of breath; asthma interferes
with activities of daily life. Chest tightness, not pain.
Aggravating Factors: Exposure to cats or dust; Burst of physical exertions “when hurrying up
or walking upstairs”.
Relieving Factors: Usually inhaler, nothing currently
Treatment: Proventil 90mcg inhaler 3 puffs every 4 hours
Current Medications
Medication Dosage Frequency Length of Reason for Use
Time Used
Proventil 90mcg 3 puffs every 25.5 years Asthma: Wheezing,
4 hours PRN Shortness of breath; Cats
Tylenol Gel 500mg 1 capsule < few weeks Headache
Caps ES PRN ago
Advil 200mg 3 tablets PRN Menstrual Cramps
Three Times
a day
Metformin Unknown 1 tablet BID 1 year age 24 Type 2 Diabetes
Past Medical History (PMHx) –
Asthma: Diagnosed age 2.5 years
Diabetes: Diagnosed age 24 years. Has not taken medications for diabetes for 3 years. Manages
diabetes by avoiding sugar and trying to stay active.
Foot Wound: A few months ago, states it is healing
Hospitalizations: State” A bunch of times as a child for asthma”; last hospitalization was age
16 years.
Chest X-ray age 16 years
X-ray foot few months ago
Surgery: Denies
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