NR509 WEEK 3 SOAP NOTE FINAL
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
170cm 88kg 139/ 82 16 98.9F 99% Medication: Penicillin (rash/ hives)
87 Food: none
Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing)
History of Present Illness (HPI)
Chief Complaint (CC) Headache CC is a BRIEF statement identifying
Onset 5 days ago why the patient is here - in the
Location Pain is located at the crown and back of head. patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Intermittent- daily-lasts for 1-2hrs per episode.
days”. Sometimes a patient has more
Characteristics Dull headache, non- radiating, associated with neck pain than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Movement of head sore throat, identify which is the CC
Relieving Factors Tylenol- improved pain to 3/10 ,rest and which may be an associated
Treatment No other treatment symptom
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
Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma
exacerbation
Flovent Patient unaware of BID Daily Mainenence for Asthma
exact dosage
Tylenol 2- regular strength Once a day Once a day for For headache
tabs 5 days
Advil 200mg PRN PRN For menstrual cramps
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
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.
, Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender.
Was not drinking alcohol. (Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for
asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last
Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old.
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.
Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church.
Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use
socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother- high cholesterol and hypertension
Father (deceased at 58 car accident 2 years ago)- Hx of Diabetes, high cholesterol and hypertension
Brother 25 y.o.- Obesity
Sister 14 yrs old- dx age 2 or 3 with asthma.
maternal grandma- HTN and high cholesterol
maternal grandpa-HTN and high cholesterol.
paternal grandma-HTN and high cholesterol
paternal grandpa- (deceased) colon cancer, HTN, diabetes.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue Denies ☐Itching Denies ☐Diplopia Denies ☐Earache Denies ☐Hoarseness Denies
☐Weakness Denies ☐Rashes Denies ☐Eye Pain Denies ☐Tinnitus Denies ☐Oral Ulcers Denies
☐Fever/Chills Denies ☐Nail Changes Denies ☐Eye redness Denies ☐Epistaxis Denies ☐Sore Throat Denies
☐Weight Gain Denies ☐Skin Color Changes ☒Vision changes blurry ☐Vertigo Denies ☐Congestion Denies
☐Weight Loss Denies Denies when does a lot of ☐Hearing Changes Denies ☐Rhinorrhea Denies
☐Trouble Sleeping Denies ☐Other: reading ☐Other:
☐Night Sweats Denies Click or tap here to ☐Photophobia Denies Click or tap here to enter text.
☐Other: enter text. ☐Eye discharge Denies
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
170cm 88kg 139/ 82 16 98.9F 99% Medication: Penicillin (rash/ hives)
87 Food: none
Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing)
History of Present Illness (HPI)
Chief Complaint (CC) Headache CC is a BRIEF statement identifying
Onset 5 days ago why the patient is here - in the
Location Pain is located at the crown and back of head. patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Intermittent- daily-lasts for 1-2hrs per episode.
days”. Sometimes a patient has more
Characteristics Dull headache, non- radiating, associated with neck pain than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Movement of head sore throat, identify which is the CC
Relieving Factors Tylenol- improved pain to 3/10 ,rest and which may be an associated
Treatment No other treatment symptom
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
Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma
exacerbation
Flovent Patient unaware of BID Daily Mainenence for Asthma
exact dosage
Tylenol 2- regular strength Once a day Once a day for For headache
tabs 5 days
Advil 200mg PRN PRN For menstrual cramps
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
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.
, Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender.
Was not drinking alcohol. (Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for
asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last
Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old.
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.
Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church.
Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use
socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother- high cholesterol and hypertension
Father (deceased at 58 car accident 2 years ago)- Hx of Diabetes, high cholesterol and hypertension
Brother 25 y.o.- Obesity
Sister 14 yrs old- dx age 2 or 3 with asthma.
maternal grandma- HTN and high cholesterol
maternal grandpa-HTN and high cholesterol.
paternal grandma-HTN and high cholesterol
paternal grandpa- (deceased) colon cancer, HTN, diabetes.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue Denies ☐Itching Denies ☐Diplopia Denies ☐Earache Denies ☐Hoarseness Denies
☐Weakness Denies ☐Rashes Denies ☐Eye Pain Denies ☐Tinnitus Denies ☐Oral Ulcers Denies
☐Fever/Chills Denies ☐Nail Changes Denies ☐Eye redness Denies ☐Epistaxis Denies ☐Sore Throat Denies
☐Weight Gain Denies ☐Skin Color Changes ☒Vision changes blurry ☐Vertigo Denies ☐Congestion Denies
☐Weight Loss Denies Denies when does a lot of ☐Hearing Changes Denies ☐Rhinorrhea Denies
☐Trouble Sleeping Denies ☐Other: reading ☐Other:
☐Night Sweats Denies Click or tap here to ☐Photophobia Denies Click or tap here to enter text.
☐Other: enter text. ☐Eye discharge Denies
