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
170 88kg 139/ 82 16 98.9 99% Medication: penicillin caused rash, hives
87 Food: none
Environment: cat and dust causes sneezing, itching eyes, asthma
exacerbation
History of Present Illness (HPI)
Chief Complaint (CC) “I got into a little fender bender a week ago and I've been getting these CC is a BRIEF statement identifying
headaches ever since. And my necks is sore too" why the patient is here - in the
Onset 5 days agos patient’s own words - for instance
Location Headaches -crown and back of her head, and neck sore in the back neck is "headache", NOT "bad headache for 3
both sides days”. Sometimes a patient has more
Duration The headaches last about one-two hours, and the neck sore has been than one complaint. For example: If
constant after accident the patient presents with cough and
Characteristics The headaches are dull ache. The neck is described "It's just been stiff and sore throat, identify which is the CC
sore since a little after the car accident. The headaches and neck sore is 3 out and which may be an associated
10. symptom
Aggravating Factors Ms. Jones reported "Nothing really makes them worse . they just sort of start,
and eventually they go away." Movements make the neck sore worse.
Relieving Factors Tylenol make the headaches and neck sore better. Resting helps with sore of
the neck
Treatment Tylenol 2 pills regular strength once of day for the headaches and neck sore,
Taking Tylenol daily since the accident and the last dose this morning
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
Tylenol 2 pills regular strength Once of a day Five days The headaches and neck sores.
Proventil 2 puffs 90mcg As needed Last use 8 For Asthmas
months ago
Flovent 2 puffs d Twice a day 8 months Asthmas
Advil Three pills of 200 mg three times a day Three -four Menstrual cycle cramps
days
, Click or tap here to enter text. 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.
The patient denied head trauma or lost conscious and denied seeing any doctor after the car accident. Denied being injured during the car
accident, only her neck sore after the accident. Reported having asthmas and diabetes, and cramps with menstrual cycle. The patient developed
asthmas at the age of 2 1/2. Last asthmas attack and hospitalization for asthma were in high school at the age of sixteen and five times
hospitalization for asthma as a child; asthmas is caused by cat, dust, and running upstairs. Dr. Dewitt is asthma doctor and denied intubation
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.
Denied smoking or family member at home, but reported exposed to secondhand smoke- friends when they go out to drink. Two-three drinks when
going out on the weekend with a friend and usually get rum with diet coke. About 6 to 10 drinks in a month. Last alcohol drinks were a couple of
weekends ago. Reported drinks are fun, but it's a huge part of her life. She denied chewing tobacco but used to smoke pot during and after high
school. Last time smoke pot at the age of 21 and smoke pot frequently. She denied using the drug. The headaches do not limit daily activities, and
the headaches are happening randomly.
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.
Denied family members with headaches.
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 denied ☐Itching Click or tap ☒Diplopia denied ☒Earache denied ☐Hoarseness Click or tap here
☒Weakness denied here to enter text. ☐Eye Pain Click or tap ☒Tinnitus denied to enter text.
☒Fever/Chills denied ☐Rashes Click or tap here to enter text. ☐Epistaxis Click or tap ☐Oral Ulcers Click or tap here
☒Weight Gain gained two here to enter text. ☐Eye redness Click or here to enter text. to enter text.
pounts ☐Nail Changes Click tap here to enter text. ☒Vertigo denied ☐Sore Throat Click or tap here
☐Weight Loss Click or tap or tap here to enter ☒Vision changes blurry ☒Hearing Changes denied to enter text.
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
170 88kg 139/ 82 16 98.9 99% Medication: penicillin caused rash, hives
87 Food: none
Environment: cat and dust causes sneezing, itching eyes, asthma
exacerbation
History of Present Illness (HPI)
Chief Complaint (CC) “I got into a little fender bender a week ago and I've been getting these CC is a BRIEF statement identifying
headaches ever since. And my necks is sore too" why the patient is here - in the
Onset 5 days agos patient’s own words - for instance
Location Headaches -crown and back of her head, and neck sore in the back neck is "headache", NOT "bad headache for 3
both sides days”. Sometimes a patient has more
Duration The headaches last about one-two hours, and the neck sore has been than one complaint. For example: If
constant after accident the patient presents with cough and
Characteristics The headaches are dull ache. The neck is described "It's just been stiff and sore throat, identify which is the CC
sore since a little after the car accident. The headaches and neck sore is 3 out and which may be an associated
10. symptom
Aggravating Factors Ms. Jones reported "Nothing really makes them worse . they just sort of start,
and eventually they go away." Movements make the neck sore worse.
Relieving Factors Tylenol make the headaches and neck sore better. Resting helps with sore of
the neck
Treatment Tylenol 2 pills regular strength once of day for the headaches and neck sore,
Taking Tylenol daily since the accident and the last dose this morning
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
Tylenol 2 pills regular strength Once of a day Five days The headaches and neck sores.
Proventil 2 puffs 90mcg As needed Last use 8 For Asthmas
months ago
Flovent 2 puffs d Twice a day 8 months Asthmas
Advil Three pills of 200 mg three times a day Three -four Menstrual cycle cramps
days
, Click or tap here to enter text. 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.
The patient denied head trauma or lost conscious and denied seeing any doctor after the car accident. Denied being injured during the car
accident, only her neck sore after the accident. Reported having asthmas and diabetes, and cramps with menstrual cycle. The patient developed
asthmas at the age of 2 1/2. Last asthmas attack and hospitalization for asthma were in high school at the age of sixteen and five times
hospitalization for asthma as a child; asthmas is caused by cat, dust, and running upstairs. Dr. Dewitt is asthma doctor and denied intubation
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.
Denied smoking or family member at home, but reported exposed to secondhand smoke- friends when they go out to drink. Two-three drinks when
going out on the weekend with a friend and usually get rum with diet coke. About 6 to 10 drinks in a month. Last alcohol drinks were a couple of
weekends ago. Reported drinks are fun, but it's a huge part of her life. She denied chewing tobacco but used to smoke pot during and after high
school. Last time smoke pot at the age of 21 and smoke pot frequently. She denied using the drug. The headaches do not limit daily activities, and
the headaches are happening randomly.
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.
Denied family members with headaches.
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 denied ☐Itching Click or tap ☒Diplopia denied ☒Earache denied ☐Hoarseness Click or tap here
☒Weakness denied here to enter text. ☐Eye Pain Click or tap ☒Tinnitus denied to enter text.
☒Fever/Chills denied ☐Rashes Click or tap here to enter text. ☐Epistaxis Click or tap ☐Oral Ulcers Click or tap here
☒Weight Gain gained two here to enter text. ☐Eye redness Click or here to enter text. to enter text.
pounts ☐Nail Changes Click tap here to enter text. ☒Vertigo denied ☐Sore Throat Click or tap here
☐Weight Loss Click or tap or tap here to enter ☒Vision changes blurry ☒Hearing Changes denied to enter text.
