SOAP

Initials: EP Age: 78 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 5’2’ 120 110/ 70 92 16 37.0 99 Medication: NKDA Food: NONE Environment: Late (itchy rash) History of Present Illness (HPI) Chief Complaint (CC) Abdominal pain and difficulty going to the bathroom CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient h...

Initials: EP Age: 78 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 5’2’ 120 110/ 70 92 16 37.0 99 Medication: NKDA Food: NONE Environment: Late (itchy rash) History of Present Illness (HPI) Chief Complaint (CC) Abdominal pain and difficulty going to the bathroom CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient h...

Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 89 kg 140/ 81 89 20 98.5 F 99% Medication: Penicillin-rash/hives Food: No known food allergies Environment: Cat dander, Dust-sneezes, pruritus, wheezing, asthma flare up History of Present Illness (HPI) Chief Complaint (CC) “I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does” CC is a BRIEF statement identifying why the patient is her...

S.O.A.P. Note Template CASE ID #EENT DOCUMENTATION 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 think I have a sinus infection” 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 This is a 42 y/o Caucasian female who presents to the medica...