NURS 623 12.2 S.O.A.P. Note Template
Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Patient demographics
Assignment 12.2 SOAP Note
Subjective History
Chief Complaint
What brought you here today…(such as a headache)
Back pain
History of Present Illness
Chronological order of events, state of health before onset of CC, must include
OLDCARTS (Onset, Location, Duration, Character, Aggravating/associated factors,
Relieving factors, Temporal factors – other things going on, Severity) in paragraph form
A 42-year-old obese female presents with complaints of lower back pain for the past
week that feels worse today. The pain is constant and intermittently radiates down her
left leg. It is not improved with ibuprofen. She works as a grocery store clerk.
Past Medical History
Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current
medications
Past medical history: None
Past surgical history: None
Patient is current in her immunizations
Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Patient demographics
Assignment 12.2 SOAP Note
Subjective History
Chief Complaint
What brought you here today…(such as a headache)
Back pain
History of Present Illness
Chronological order of events, state of health before onset of CC, must include
OLDCARTS (Onset, Location, Duration, Character, Aggravating/associated factors,
Relieving factors, Temporal factors – other things going on, Severity) in paragraph form
A 42-year-old obese female presents with complaints of lower back pain for the past
week that feels worse today. The pain is constant and intermittently radiates down her
left leg. It is not improved with ibuprofen. She works as a grocery store clerk.
Past Medical History
Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current
medications
Past medical history: None
Past surgical history: None
Patient is current in her immunizations
