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 88 kg 139/ 82 16 98.9 F 99% Medication: Penicillin-Rash/Hives
cm 87 Food: No known food allergies
Environment: Cats & Dust-Sneezing, itchy eyes, asthma flare ups.
History of Present Illness (HPI)
Chief Complaint (CC) “Well I got into a fender bender a week ago and I’ve been getting these CC is a BRIEF statement identifying
headaches ever since and my neck is sore too”
why the patient is here - in the
Onset 5 days ago ( days post accident) patient’s own words - for instance
Location Head and neck "headache", NOT "bad headache for
Duration Headache occurs once a day, last 1-2 hours 3days”. Sometimes a patient has
Characteristics Dull ache in the crown and back of the head bilaterally, pain in the bilateral morethan one complaint. For
temples and behind the eyes. example: If the patient presents with
Aggravating Factors Denies any aggravating factors for headache, but states neck soreness is cough and sore throat, identify which
exacerbated and painful with movement of the head/neck. is the CC and which may be an
Relieving Factors Tylenol and rest associated symptom
Treatment Currently takes Tylenol 2 regular strength one a day for headache and neck
pain since accident.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
, 2
Medication Length of
Dosage Frequency Time Reason for Use
(Rx, OTC, or
Homeopathic) Used
Tylenol (Acetaminophen) Two 325mg tablets Once a day 7 days Daily headaches, and neck pain
Regular Strength
Proventil Inhaler (Albuterol) 90 mcg (1-2) puffs PRN as needed. (last Since diagnosis Asthma Exacerbation
used8 months ago) of asthma
atage 2.5
Advil (Ibuprofen) Three 200mg tablets PRN up to three times Unknown, Takes during menstrual cycle
aday takesduring forcramps
menstrual cycle
Flovent 44 mcg (2 puffs) Daily BID New Asthma
prescription
, 3
aprox 8 months
ago
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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.
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