S.O.A.P. Note Template CASE ID# Tina Jones Neurological

Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) C hief C o m plaint What brought you here today (eg. headache) “I got into a little fender bender a week ago and I've been getting these headaches ever since.” Histo r y of P r ese nt Illn ess Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient is a 28-year-old African American woman who presented to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. She states that she was a restrained passenger in an accident in a parking lot one week ago. She believes the speed to be approximately 5-10 mph. She did not seek emergent care and felt no symptoms after the accident. She was not under the influence at the time of the accident. Two days later she developed a dull ache in bilateral temporal regions accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She reports her neck pain a 3/10. She did not lose consciousness in the accident. She denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She reports her head pain 4/10 at its worst. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She reports her symptoms also improve with rest. She denies nausea, vomiting, sensitivity to light. She denies ringing in her ears. She denies history of headaches. Location Duration Character Aggravating/associate d factors Relieving factors Temporal factors – other things going