SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: T.J Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 90 kg 142/ 86 19 101.1 99 RA1 Medication: Penicillin= Rash/Hives Denies latex allergy
cm 82 Food: No Known Allergies
Environment: Cat Dander & Dust = sneezing, itchy eyes, wheezing
History of Present Illness (HPI)
Chief Complaint (CC) Foot pain CC is a BRIEF statement identifying
Onset 1 week ago why the patient is here - in the
Location Plantar surface of right foot patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Initial injury a week ago with worsen pain over last 2 days
days”. Sometimes a patient has more
Characteristics Throbbing and Sharp with standing than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Weight-bearing sore throat, identify which is the CC
Relieving Factors Pain medications and Rest and which may be an associated
Treatment Cleans wound with peroxide, applies Neosporin, and changes dressings twice symptom
a day
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
(Rx, OTC, or Homeopathic)
Dosage Frequency Used Reason for Use
Tramadol 50 mg Three (3) times per day 2 days ago Pain relief
Metformin Unknown 1 pill twice per day Took 3 years Diabetes
ago
Albuterol Inhaler 90 mcg As Needed 2-3 times per 3 days ago Ashtma
day
Advil 200mg As needed As needed Menstrual Cramps
Tylenol 500mg As need Once a week As Needed Headaches
Neosporin 1 application Twice a day 1 week Wound infection
This study source was downloaded by 100000821441832 from CourseHero.com on 04-17-2021 23:10:13 GMT -05:00
, 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.
This study source was downloaded by 100000821441832 from CourseHero.com on 04-17-2021 23:10:13 GMT -05:00
S: Subjective
Information the patient or patient representative told you
Initials: T.J Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 90 kg 142/ 86 19 101.1 99 RA1 Medication: Penicillin= Rash/Hives Denies latex allergy
cm 82 Food: No Known Allergies
Environment: Cat Dander & Dust = sneezing, itchy eyes, wheezing
History of Present Illness (HPI)
Chief Complaint (CC) Foot pain CC is a BRIEF statement identifying
Onset 1 week ago why the patient is here - in the
Location Plantar surface of right foot patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Initial injury a week ago with worsen pain over last 2 days
days”. Sometimes a patient has more
Characteristics Throbbing and Sharp with standing than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Weight-bearing sore throat, identify which is the CC
Relieving Factors Pain medications and Rest and which may be an associated
Treatment Cleans wound with peroxide, applies Neosporin, and changes dressings twice symptom
a day
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
(Rx, OTC, or Homeopathic)
Dosage Frequency Used Reason for Use
Tramadol 50 mg Three (3) times per day 2 days ago Pain relief
Metformin Unknown 1 pill twice per day Took 3 years Diabetes
ago
Albuterol Inhaler 90 mcg As Needed 2-3 times per 3 days ago Ashtma
day
Advil 200mg As needed As needed Menstrual Cramps
Tylenol 500mg As need Once a week As Needed Headaches
Neosporin 1 application Twice a day 1 week Wound infection
This study source was downloaded by 100000821441832 from CourseHero.com on 04-17-2021 23:10:13 GMT -05:00
, 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.
This study source was downloaded by 100000821441832 from CourseHero.com on 04-17-2021 23:10:13 GMT -05:00
