SOAP NOTE PATIENT ENCOUNTER
S.O.A.P. Note Template CASE ID #EENT DOCUMENTATION
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
ComplaintChief
What brought you here
“I think I have a sinus infection”
today…(eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
History of Present Illness
Onset This is a 42 y/o Caucasian female who presents to the medical office
Location complaining of severe headache and pain in the past two weeks. She
Duration suspects that it is a “sinus infection”. She further reported that she had
Character experienced sinus infection three times for the past 6 months. She reports
Aggravating/associate sinus pressure in addition to coughing at night, terrible congestion, and sore
d factors throat. She further explains that she experiences pain above and below her
Relieving factors ears in addition to what feels like “pressure in the ears when she swallows”.
Temporal factors – However, she denies any difficulties with breathing, having wheeze, and
other things going on chest pains. She also refutes night chills and sweats; hence, she does not
think she has fever. She reports having been taking Tylenol and Sufaded to
Severity relieve headache but she does not think that they have helped her.
Adult Illnesses, Adult illnesses: Sinus infections three times in the past 6 months.
Medical
History
childhood illnesses, Childhood illnesses/Immunizations: Not addressed.
Past
immunizations, Allergies: Allergic to Aspirin.
surgeries, allergies, Surgeries: 5 years ago, had nasal polyps removed.
current medications Current medication: Tylenol to relief headache.
Include Parents,
History
Family
siblings; grandparents
Family history: Not addressed.
if applicable/known,
cause of death, age,
pertinent medical
Education, marital
Personal/Social
status, occupation,
alcohol/drug use,
History
smoking status, sexual No education, marital status, occupation, alcohol/drug use, smoking or
history if relevant, sexual status is assessed.
exercise, nutrition,
religious preference if
known
Review of Systems
General: Positive for fatigue, negative for fever, chills or night sweat
Hair, Skin, & Nails: Not assessed in the interview
Head: Positive for severe headache and sinus pressure
Neck: Not assessed in the interview.
Eyes: Not assessed in the interview.
Ears: Positive for right ear pain and pressure
Nose: from
This study source was downloaded by 100000844708667 Positive for drainage
CourseHero.com and 20:19:48
on 09-10-2022 congestion, negative for loss of smell
GMT -05:00
https://www.coursehero.com/file/63326014/PATIENT-ENCOUNTER-SOAP-NOTEdocx/
S.O.A.P. Note Template CASE ID #EENT DOCUMENTATION
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
ComplaintChief
What brought you here
“I think I have a sinus infection”
today…(eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
History of Present Illness
Onset This is a 42 y/o Caucasian female who presents to the medical office
Location complaining of severe headache and pain in the past two weeks. She
Duration suspects that it is a “sinus infection”. She further reported that she had
Character experienced sinus infection three times for the past 6 months. She reports
Aggravating/associate sinus pressure in addition to coughing at night, terrible congestion, and sore
d factors throat. She further explains that she experiences pain above and below her
Relieving factors ears in addition to what feels like “pressure in the ears when she swallows”.
Temporal factors – However, she denies any difficulties with breathing, having wheeze, and
other things going on chest pains. She also refutes night chills and sweats; hence, she does not
think she has fever. She reports having been taking Tylenol and Sufaded to
Severity relieve headache but she does not think that they have helped her.
Adult Illnesses, Adult illnesses: Sinus infections three times in the past 6 months.
Medical
History
childhood illnesses, Childhood illnesses/Immunizations: Not addressed.
Past
immunizations, Allergies: Allergic to Aspirin.
surgeries, allergies, Surgeries: 5 years ago, had nasal polyps removed.
current medications Current medication: Tylenol to relief headache.
Include Parents,
History
Family
siblings; grandparents
Family history: Not addressed.
if applicable/known,
cause of death, age,
pertinent medical
Education, marital
Personal/Social
status, occupation,
alcohol/drug use,
History
smoking status, sexual No education, marital status, occupation, alcohol/drug use, smoking or
history if relevant, sexual status is assessed.
exercise, nutrition,
religious preference if
known
Review of Systems
General: Positive for fatigue, negative for fever, chills or night sweat
Hair, Skin, & Nails: Not assessed in the interview
Head: Positive for severe headache and sinus pressure
Neck: Not assessed in the interview.
Eyes: Not assessed in the interview.
Ears: Positive for right ear pain and pressure
Nose: from
This study source was downloaded by 100000844708667 Positive for drainage
CourseHero.com and 20:19:48
on 09-10-2022 congestion, negative for loss of smell
GMT -05:00
https://www.coursehero.com/file/63326014/PATIENT-ENCOUNTER-SOAP-NOTEdocx/
