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SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: EJ Age: 78 Gender: F
Heig Weig BP HR RR Tem SPO2 Pain Allergies (and reaction)
ht ht p Rating
5’2 120lb 110 92 16 37.0 99% Medication: Click or tap here
s / C
to enter text. Food: Click or
70
tap here to enter text.
Environment: Latex – Contact Dermatitis
History of Present Illness (HPI)
Chief Complaint Abdominal pain and trouble going to the bathroom CC is a BRIEF
(CC) for 5 days
Onset 5 days ago statement identifying
Location Abdomen why the patient is here -
Duration Continuous in the patient’s own
Characteristics “Dull, crampy pain, an uneasiness in belly” words - for instance
Aggravating Activity, consumption of food "headache", NOT "bad
Factors headache for 3 days”.
Relieving Rest Sometimes a patient
Factors
has more than one
Treatment Rest, patient has not tried any treatment for
, 2
constipation complaint. For example:
If the patient presents
with cough and sore
throat, identify which is
the CC and which may
be an associated
symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also
include OTC or homeopathic products.
Medication Length of
(Rx, OTC, or Dosage Frequency Time Reason for Use
Homeopathic) Used
Accupril 10mg By mouth once Unknown Hypertension
daily
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.
Patient was diagnosed with hypertension at the age of 54. Past surgeries include
cholecystectomy at age 42 and C-Section at age 40. Only
hospitalizations were for listed surgeries and two other vaginal childbirths. G3P3L2 Reports
immunizations are current but has not had the influenza vaccine this year.
, 3
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.
Patient follows up with the Shadow Health clinic every 6 month and is compliant with
treatment. Sexually active with monogamous male partner, though denies vaginal intercourse
and states they only have oral sex. Denies any testing for STIs. Reports diet to be “light”
consisting of low, fat, lean meats, low sugar and heart healthy diet, though low in fruits,
vegetables and fiber. Participates in regular exercise classes. Maintains independence with
mobility. Lives with daughter. Denies any tobacco or illicit drug use or exposure to either.
Drinks one glass of wine on Sundays.
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.
Mother: Deceased at age 88, HTN, DMII, CVA
Father: Deceased at 82, HTN,
hypercholesterolemia, MI Maternal
grandparents: family hx CAD, DMII
Paternal grandparents: Obesity, CVA, HTN, Lung CA
Siblings: Brother, 80, HTN,
hypercholesterolemia, prostate CA,
Brother, 81, HTN
