SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: BF Age: 58 Gender: Male
Height Weig BP HR RR Temp SPO2 Pain Allergies
ht
5’11” 195lb L- 104 16 36.7 C 98 5/10 Medication: codeine- nausea & vomiting
146/88 Environmental: none
R-
146/90
History of Present Illness (HPI)
Chief Complaint (CC) States he has been “experiencing this tight, uncomfortable feeling in CC is a BRIEF statement identifying
my chest every now and then”. why the patient is here - in the patient’s
Onset A month own words - for instance "headache",
Location Chest NOT "bad headache for 3 days”.
Sometimes a patient has more than
Duration Lasts for a few minutes and then goes away with rest. one complaint. For example: If the
Characteristics Describe as “tight and uncomfortable” in the middle of his chest. patient presents with cough and sore
throat, identify which is the CC and
Aggravating Factors Physical activities such as yardwork or climbing stairs which may be an associated symptom
Relieving Factors Rest
Treatment none
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Metoprolol 100mg PO Daily unknown hypertension
Atorvastatin 20mg PO Daily @ HS unknown hyperlipidemia
Omega 3 Fishoil (OTC 1200 mg PO BID unknown Heart health
supplement)
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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.
Hypertension-Stage II, diagnosed 1 year ago
Hyperlipidemia-Diagnosed 1 year ago
No surgical history
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.
-No past or present tobacco use
-Reports drinking 2-3 alcoholic beverages (beer) per week
Hasn’t used illicit drugs in 30 years- LSD, pot, cocaine and shrooms. Denies using drugs now.
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.
-Father : Hypertension, hyperlipidemia, obesity, died of colon cancer, age 75
-Mother: Type 2 diabetes, hypertension, age 80
-Brother: Died age 24 in motor vehicle accident
-Sister: Type 2 diabetes, hypertension, age 52
-Maternal grandmother: Died of breast cancer. Age 65
-Maternal grandfather: Died of heart attack , age 54 -paternal grandmother: Died of pneumonia, age 78
-Paternal grandfather : Died of old age , age 85
-Daughter: Asthma, age 19
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue related to not ☐Itching denies ☐Diplopia denies ☐Earache denies ☐Hoarseness denies
sleeping well ☐Rashes denies ☐Eye Pain denies ☐Tinnitus denies ☐Oral Ulcers denies
☐Weakness denies ☐Nail Changes denies ☐Eye redness denies ☐Epistaxis denies ☐Sore Throat denies
☐Fever/Chills denies ☐Skin Color Changes ☐Vision changes - denies ☐Vertigo denies ☐Congestion denies
☐Weight Gain 20 lbs denies ☐Photophobia denies ☐Hearing Changes: denies ☐Rhinorrhea denies
S: Subjective
Information the patient or patient representative told you
Initials: BF Age: 58 Gender: Male
Height Weig BP HR RR Temp SPO2 Pain Allergies
ht
5’11” 195lb L- 104 16 36.7 C 98 5/10 Medication: codeine- nausea & vomiting
146/88 Environmental: none
R-
146/90
History of Present Illness (HPI)
Chief Complaint (CC) States he has been “experiencing this tight, uncomfortable feeling in CC is a BRIEF statement identifying
my chest every now and then”. why the patient is here - in the patient’s
Onset A month own words - for instance "headache",
Location Chest NOT "bad headache for 3 days”.
Sometimes a patient has more than
Duration Lasts for a few minutes and then goes away with rest. one complaint. For example: If the
Characteristics Describe as “tight and uncomfortable” in the middle of his chest. patient presents with cough and sore
throat, identify which is the CC and
Aggravating Factors Physical activities such as yardwork or climbing stairs which may be an associated symptom
Relieving Factors Rest
Treatment none
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Metoprolol 100mg PO Daily unknown hypertension
Atorvastatin 20mg PO Daily @ HS unknown hyperlipidemia
Omega 3 Fishoil (OTC 1200 mg PO BID unknown Heart health
supplement)
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
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.
Hypertension-Stage II, diagnosed 1 year ago
Hyperlipidemia-Diagnosed 1 year ago
No surgical history
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.
-No past or present tobacco use
-Reports drinking 2-3 alcoholic beverages (beer) per week
Hasn’t used illicit drugs in 30 years- LSD, pot, cocaine and shrooms. Denies using drugs now.
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.
-Father : Hypertension, hyperlipidemia, obesity, died of colon cancer, age 75
-Mother: Type 2 diabetes, hypertension, age 80
-Brother: Died age 24 in motor vehicle accident
-Sister: Type 2 diabetes, hypertension, age 52
-Maternal grandmother: Died of breast cancer. Age 65
-Maternal grandfather: Died of heart attack , age 54 -paternal grandmother: Died of pneumonia, age 78
-Paternal grandfather : Died of old age , age 85
-Daughter: Asthma, age 19
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
☐Fatigue related to not ☐Itching denies ☐Diplopia denies ☐Earache denies ☐Hoarseness denies
sleeping well ☐Rashes denies ☐Eye Pain denies ☐Tinnitus denies ☐Oral Ulcers denies
☐Weakness denies ☐Nail Changes denies ☐Eye redness denies ☐Epistaxis denies ☐Sore Throat denies
☐Fever/Chills denies ☐Skin Color Changes ☐Vision changes - denies ☐Vertigo denies ☐Congestion denies
☐Weight Gain 20 lbs denies ☐Photophobia denies ☐Hearing Changes: denies ☐Rhinorrhea denies
