Focused SOAP Note Template
Student’s Name:
Institutional Affiliation:
Course Name:
Instructor’s Name:
Date:
1
, Patient Information:
Initials: D.K.
Age: 34
Sex: Male
Race: Caucasian-American
S.
CC (chief complaint): "I have been experiencing redness and itchiness in both eyes".
HPI: D.K. is a 34-year-old Caucasian-American male who visits the clinic for a medical
examination after experiencing redness and itchiness in both eyes. The following aspects
illustrate the patient's medical status.
Location: Head
Onset: 3 days ago
Character: Pounding, pressure around the eyes and temples
Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
Timing: After being on the computer all day at work
Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely
better
Severity: 7/10 pain scale
Current Medications: The patient is taking acetaminophen (Tylenol) 1300 mg) P.O. q8hr
PRN to relieve pain. The patient accessed acetaminophen (Tylenol) over the counter.
Allergies: He is allergic to dust and pollen.
PMHx: The patient received his last tetanus on 28th December 2023. He denies past major
illnesses or surgeries.
2
Student’s Name:
Institutional Affiliation:
Course Name:
Instructor’s Name:
Date:
1
, Patient Information:
Initials: D.K.
Age: 34
Sex: Male
Race: Caucasian-American
S.
CC (chief complaint): "I have been experiencing redness and itchiness in both eyes".
HPI: D.K. is a 34-year-old Caucasian-American male who visits the clinic for a medical
examination after experiencing redness and itchiness in both eyes. The following aspects
illustrate the patient's medical status.
Location: Head
Onset: 3 days ago
Character: Pounding, pressure around the eyes and temples
Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
Timing: After being on the computer all day at work
Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely
better
Severity: 7/10 pain scale
Current Medications: The patient is taking acetaminophen (Tylenol) 1300 mg) P.O. q8hr
PRN to relieve pain. The patient accessed acetaminophen (Tylenol) over the counter.
Allergies: He is allergic to dust and pollen.
PMHx: The patient received his last tetanus on 28th December 2023. He denies past major
illnesses or surgeries.
2
