COMPREHENSIVE SOAP NOTE 1
Comprehensive SOAP
Note
Patient Initials: M.L. Age: _65 y.o._ Gender: M
SUBJECTIVE DATA:
Chief Complaint (CC): “I am fine”
History of Present Illness (HPI): 65-year-old Caucasian female admitted to this facility
under a Baker Act for suicidal ideation, assaulting a nurse, and reporting urges to slap her
roommate at the SNF with a belt.
Medications:
Aspirin 81 mg PO daily, Lipitor 40 mg PO HS, Coreg 6.25 mg OP BID, Cozaar 25 mg PO
daily, Gabapentin 300 mg PO TID , Keppra 500 mg PO BID, Vimpat 150 PO BID,
Protonix 40 mg PO daily, Ambian 10 mg PO HS , Melatonin 3 mg PO HS, Baclofen 20 mg
PO BID , Colace 100 mg PO daily
After reviewing this patient’s current medications and comparing them with the
Beers Criteria, I have discovered that most of the medications this patient is taking are
appropriate for her age. The provider might want to reconsider the use of Ambian for this
patient, as the Beers Criteria suggests avoidance in patient with a history of falls or
cognitive impairment. The provider would also want to take the patients kidney function
in to account prior to prescribing a high does of gabapentin, since the Beers Criteria
recommends a lower dose of this medication in patient’s who’s creatinine clearance is less
than 60 mL/min (American Geriatrics Society, 2015). Allergies: Dilantin, erythromycin,
penicillin, sulfa, benzodiazepines, morphine, Tylenol, tape, mangos
, COMPREHENSIVE SOAP NOTE 2
Past Medical History (PMH): HTN, irregular heartbeat, hypothyroid, diabetes mellitus,
GERD, bipolar, depression, osteoarthritis, anemia, seizures, thrombocytopenia,
hypercholesterolemia, CVA, neuropathy, subdural hematoma from a fall 2016
Past Surgical History (PSH): Hysterectomy (20 years ago), cholecystectomy (15 years
ago), cervical fusion (2016).
Personal/Social History: Patient denies tobacco, alcohol, or drug use. She is a retired RN.
Immunization History: Patient says she is up to date on her vaccinations and that she did
receive a flu shot this year because it is required by the SNF she lives in
Significant Family History: Include history of parents, grandparents, siblings, and
children. Lifestyle: The patient lives in a skilled nursing facility and is wheelchair
bound due to “weakness”. Her husband lives in the same facility and “used to drink
too much.”
Review of Systems:
General: Patients is sitting in a wheelchair with her head down on a windowsill. She is
dressed appropriately and appears well nourished. She denies any recent fever, chills,
nausea, or weight loss. She says that she has felt weak and fatigued but this is not a new
symptom and it is caused by her depression.
HEENT: The patient denies any headache, dizziness, or neck stiffness. She denies any
swelling, tenderness, or masses. The patient denies any visual changes, or redness, swelling,
drainage, or pain in the eyes. The patient denies any hearing loss, pain, discharge, vertigo,
or tinnitus. The patient denies any epistaxis, itching, or rhinorrhea. She denies bleeding
gums, or mouth sores.
She has a full set of dentures that she says are well fitting. The patient denies a sore throat,
hoarseness, or change in taste.
Breasts: Patient denies any pain, lumps, or discharge.
Comprehensive SOAP
Note
Patient Initials: M.L. Age: _65 y.o._ Gender: M
SUBJECTIVE DATA:
Chief Complaint (CC): “I am fine”
History of Present Illness (HPI): 65-year-old Caucasian female admitted to this facility
under a Baker Act for suicidal ideation, assaulting a nurse, and reporting urges to slap her
roommate at the SNF with a belt.
Medications:
Aspirin 81 mg PO daily, Lipitor 40 mg PO HS, Coreg 6.25 mg OP BID, Cozaar 25 mg PO
daily, Gabapentin 300 mg PO TID , Keppra 500 mg PO BID, Vimpat 150 PO BID,
Protonix 40 mg PO daily, Ambian 10 mg PO HS , Melatonin 3 mg PO HS, Baclofen 20 mg
PO BID , Colace 100 mg PO daily
After reviewing this patient’s current medications and comparing them with the
Beers Criteria, I have discovered that most of the medications this patient is taking are
appropriate for her age. The provider might want to reconsider the use of Ambian for this
patient, as the Beers Criteria suggests avoidance in patient with a history of falls or
cognitive impairment. The provider would also want to take the patients kidney function
in to account prior to prescribing a high does of gabapentin, since the Beers Criteria
recommends a lower dose of this medication in patient’s who’s creatinine clearance is less
than 60 mL/min (American Geriatrics Society, 2015). Allergies: Dilantin, erythromycin,
penicillin, sulfa, benzodiazepines, morphine, Tylenol, tape, mangos
, COMPREHENSIVE SOAP NOTE 2
Past Medical History (PMH): HTN, irregular heartbeat, hypothyroid, diabetes mellitus,
GERD, bipolar, depression, osteoarthritis, anemia, seizures, thrombocytopenia,
hypercholesterolemia, CVA, neuropathy, subdural hematoma from a fall 2016
Past Surgical History (PSH): Hysterectomy (20 years ago), cholecystectomy (15 years
ago), cervical fusion (2016).
Personal/Social History: Patient denies tobacco, alcohol, or drug use. She is a retired RN.
Immunization History: Patient says she is up to date on her vaccinations and that she did
receive a flu shot this year because it is required by the SNF she lives in
Significant Family History: Include history of parents, grandparents, siblings, and
children. Lifestyle: The patient lives in a skilled nursing facility and is wheelchair
bound due to “weakness”. Her husband lives in the same facility and “used to drink
too much.”
Review of Systems:
General: Patients is sitting in a wheelchair with her head down on a windowsill. She is
dressed appropriately and appears well nourished. She denies any recent fever, chills,
nausea, or weight loss. She says that she has felt weak and fatigued but this is not a new
symptom and it is caused by her depression.
HEENT: The patient denies any headache, dizziness, or neck stiffness. She denies any
swelling, tenderness, or masses. The patient denies any visual changes, or redness, swelling,
drainage, or pain in the eyes. The patient denies any hearing loss, pain, discharge, vertigo,
or tinnitus. The patient denies any epistaxis, itching, or rhinorrhea. She denies bleeding
gums, or mouth sores.
She has a full set of dentures that she says are well fitting. The patient denies a sore throat,
hoarseness, or change in taste.
Breasts: Patient denies any pain, lumps, or discharge.
