SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 years old Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
170cm 90kg 142/ 86 19 101.1F 99% Medication: Penicillin: hives/rash
82 Food: none
Environment: Dust, Cats: watery, itchy eyes, sneezing, and exacerbation
of asthma
History of Present Illness (HPI)
Chief Complaint (CC) Initial primary care visit and evaluation of infected foot wound CC is a BRIEF statement identifying
Onset One week ago but pain has intensified over the past 2 days why the patient is here - in the
Location Plantar aspect of right foot patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 7 days, but the pain has been constant for the last 2 days
days”. Sometimes a patient has more
Characteristics Throbs with a sharp pain when weight-bearing that radiates to ankle. Purulent than one complaint. For example: If
drainage without an odor. Area around the scape has erythema and edema. the patient presents with cough and
Aggravating Factors Weight-bearing, walking, touching wound and surrounding areas of foot sore throat, identify which is the CC
and which may be an associated
Relieving Factors Medication (Tramadol), rest
symptom
Treatment Was seen in ED at time of injury. Prescribed Tramadol and advised to keep
wound clean and dry. Has been cleaning with hydrogen peroxide and applying
Neosporin with dressing change.
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
Tramadol 100mg Three times daily 2 days Right foot pain
Proventil HFA inhaler (90mcg) 2-3 puffs As needed 25.5 years Shortness of breath and asthma
Tylenol 500mg As needed Uses Headaches
intermittently
Ibuprofen (Advil) 600mg As needed Uses Menstrual Cramps
intermittently
Neosporin 1 application Twice daily with dressing 1 week Prevent wound infection
, change
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.
Past medical history of type 2 diabetes that was diagnosed at age 24 and asthma that was diagnosed when she was 2.5 years old. Had a tetanus
booster last year, denies having an influenza vaccine this season. Hospitalized at age 16 for an asthma attack, denies having any surgeries.
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.
Employed full-time as a supervisor at Mid-American Copy and Ship, working on a bachelor’s degree in accounting. Hobbies include watching
TV/DVDs, reading books, and attending free talks at church. Patient is a Baptist. The patient is single with no children and lives with her mother and
sister. Also has a living brother and a father who died in a car accident last year. Denies tobacco use, was a former user of Marijuana (stopped at
age 21), drinks two to three rum and diet cokes two times a week or less. Drinks four diet sodas daily, uses a seatbelt while in a vehicle, has
working smoke detectors within the home, and is sexually attracted to men only. Denies being sexually active for the past two years, denies using
contraceptives. Does not perform self-breast exams and denies wearing sunscreen regularly. Last pap smear was four years ago, the patient has
not seen an eye doctor since she was a child in school, admits to not seeing a dentist for the last few years, and has not seen a medical provider in
two years.
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.
Father- Deceased from motor vehicle accident last year. History of type 2 diabetes, hypertension, hypercholesterolemia
Mother- Hypertension, hypercholesterolemia
Sister- Asthma
Brother- Obesity
Maternal Grandmother- Deceased due to a stroke (Patient advises grandmother was in her 70s when she passed)
Maternal Grandfather- Deceased due to a heart attack (Patient advises grandfather was in his 70s when he passed)
Paternal Grandmother- Hypertension, hypercholesterolemia
Paternal Grandfather-Deceased due to colon cancer when he was 65 years old
The patient has no children
S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 years old Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
170cm 90kg 142/ 86 19 101.1F 99% Medication: Penicillin: hives/rash
82 Food: none
Environment: Dust, Cats: watery, itchy eyes, sneezing, and exacerbation
of asthma
History of Present Illness (HPI)
Chief Complaint (CC) Initial primary care visit and evaluation of infected foot wound CC is a BRIEF statement identifying
Onset One week ago but pain has intensified over the past 2 days why the patient is here - in the
Location Plantar aspect of right foot patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration 7 days, but the pain has been constant for the last 2 days
days”. Sometimes a patient has more
Characteristics Throbs with a sharp pain when weight-bearing that radiates to ankle. Purulent than one complaint. For example: If
drainage without an odor. Area around the scape has erythema and edema. the patient presents with cough and
Aggravating Factors Weight-bearing, walking, touching wound and surrounding areas of foot sore throat, identify which is the CC
and which may be an associated
Relieving Factors Medication (Tramadol), rest
symptom
Treatment Was seen in ED at time of injury. Prescribed Tramadol and advised to keep
wound clean and dry. Has been cleaning with hydrogen peroxide and applying
Neosporin with dressing change.
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
Tramadol 100mg Three times daily 2 days Right foot pain
Proventil HFA inhaler (90mcg) 2-3 puffs As needed 25.5 years Shortness of breath and asthma
Tylenol 500mg As needed Uses Headaches
intermittently
Ibuprofen (Advil) 600mg As needed Uses Menstrual Cramps
intermittently
Neosporin 1 application Twice daily with dressing 1 week Prevent wound infection
, change
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.
Past medical history of type 2 diabetes that was diagnosed at age 24 and asthma that was diagnosed when she was 2.5 years old. Had a tetanus
booster last year, denies having an influenza vaccine this season. Hospitalized at age 16 for an asthma attack, denies having any surgeries.
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.
Employed full-time as a supervisor at Mid-American Copy and Ship, working on a bachelor’s degree in accounting. Hobbies include watching
TV/DVDs, reading books, and attending free talks at church. Patient is a Baptist. The patient is single with no children and lives with her mother and
sister. Also has a living brother and a father who died in a car accident last year. Denies tobacco use, was a former user of Marijuana (stopped at
age 21), drinks two to three rum and diet cokes two times a week or less. Drinks four diet sodas daily, uses a seatbelt while in a vehicle, has
working smoke detectors within the home, and is sexually attracted to men only. Denies being sexually active for the past two years, denies using
contraceptives. Does not perform self-breast exams and denies wearing sunscreen regularly. Last pap smear was four years ago, the patient has
not seen an eye doctor since she was a child in school, admits to not seeing a dentist for the last few years, and has not seen a medical provider in
two years.
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.
Father- Deceased from motor vehicle accident last year. History of type 2 diabetes, hypertension, hypercholesterolemia
Mother- Hypertension, hypercholesterolemia
Sister- Asthma
Brother- Obesity
Maternal Grandmother- Deceased due to a stroke (Patient advises grandmother was in her 70s when she passed)
Maternal Grandfather- Deceased due to a heart attack (Patient advises grandfather was in his 70s when he passed)
Paternal Grandmother- Hypertension, hypercholesterolemia
Paternal Grandfather-Deceased due to colon cancer when he was 65 years old
The patient has no children
