lOMoARcPSD|14763824
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: EP Age: 78 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
5’2’ 120 110/ 92 16 37.0 99 Medication: NKDA
70 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
Onset 5 days ago why the patient is here - in the
Location Low in abdomen patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Constant for 5 days
days”. Sometimes a patient has more
Characteristics Dull and crampy than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Eating and physical activity sore throat, identify which is the CC
Relieving Factors Resting and which may be an associated
symptom
Treatment Sips of warm water with no relief
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
Accupril 10mg daily Unknown Hypertension
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, lOMoARcPSD|14763824
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.
History of hypertension diagnosed at age 54. Annual exam by PCP 4 months ago, reports tests as normal. Reports that she does not check her
blood pressure but believes that at her last PCP visit it was 125/80. Reports a surgical history of cholecystectomy and 1 C-section for a still born
child, reports being hospitalized for both surgeries and the birth of her 2 living children. Reports a history of diarrhea about 6 months ago. Reports
being up to date on all immunizations, does not remember the date of her last T Dap, and has not received the flu vaccine this season. She reports
getting her Covid vaccine. Reports having a constant abdominal pain for about 5 days which started as a 1-2 and is now a 6 on a 0-10 pain scale.
Reports a recent bout of diarrhea about 3-4 times in one day, also reports that she had diarrhea about 6 months ago. Denies history of
constipation, nausea/vomiting, denies blood or mucous in stool. She does not take vitamins or supplements, denies taking otc or other pain
medication.
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 is widowed and lives with her daughter and family. She reports that she was married for 50 years, and her husband Shin passed away six
years ago. She has a gentleman friend named Max who she has being seeing for almost a year. She reports that she is sexually active, denies
using a condom and has never been diagnosed with a sexually transmitted infection. She reports that she does not have vaginal intercourse but do
other “pleasurable things”. Denies cigarette smoking and tobacco use, denies being exposed to secondhand smoke. Denies history of illicit drug
use. Reports drinking 1 glass of white wine weekly. Reports being active and exercising daily. Reports helping with household chores.
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, cause of death CVA with history of HTN, DM II Father: deceased at age 82, passed away in his sleep with history of
HTN, hypercholesterolemia, obesity; Maternal grandmother: history of DM II Maternal grandfather: Died from heart attack with history of coronary
artery disease Paternal grandmother: HTN, died from cancer Paternal grandfather: died in his sleep without any known medical history Siblings:
Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA Brother, 81: HTN Son: Healthy age 48 Daughter: Healthy age 46
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: EP Age: 78 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
5’2’ 120 110/ 92 16 37.0 99 Medication: NKDA
70 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
Onset 5 days ago why the patient is here - in the
Location Low in abdomen patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Constant for 5 days
days”. Sometimes a patient has more
Characteristics Dull and crampy than one complaint. For example: If
the patient presents with cough and
Aggravating Factors Eating and physical activity sore throat, identify which is the CC
Relieving Factors Resting and which may be an associated
symptom
Treatment Sips of warm water with no relief
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
Accupril 10mg daily Unknown Hypertension
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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.
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.
Type your text
, lOMoARcPSD|14763824
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.
History of hypertension diagnosed at age 54. Annual exam by PCP 4 months ago, reports tests as normal. Reports that she does not check her
blood pressure but believes that at her last PCP visit it was 125/80. Reports a surgical history of cholecystectomy and 1 C-section for a still born
child, reports being hospitalized for both surgeries and the birth of her 2 living children. Reports a history of diarrhea about 6 months ago. Reports
being up to date on all immunizations, does not remember the date of her last T Dap, and has not received the flu vaccine this season. She reports
getting her Covid vaccine. Reports having a constant abdominal pain for about 5 days which started as a 1-2 and is now a 6 on a 0-10 pain scale.
Reports a recent bout of diarrhea about 3-4 times in one day, also reports that she had diarrhea about 6 months ago. Denies history of
constipation, nausea/vomiting, denies blood or mucous in stool. She does not take vitamins or supplements, denies taking otc or other pain
medication.
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 is widowed and lives with her daughter and family. She reports that she was married for 50 years, and her husband Shin passed away six
years ago. She has a gentleman friend named Max who she has being seeing for almost a year. She reports that she is sexually active, denies
using a condom and has never been diagnosed with a sexually transmitted infection. She reports that she does not have vaginal intercourse but do
other “pleasurable things”. Denies cigarette smoking and tobacco use, denies being exposed to secondhand smoke. Denies history of illicit drug
use. Reports drinking 1 glass of white wine weekly. Reports being active and exercising daily. Reports helping with household chores.
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, cause of death CVA with history of HTN, DM II Father: deceased at age 82, passed away in his sleep with history of
HTN, hypercholesterolemia, obesity; Maternal grandmother: history of DM II Maternal grandfather: Died from heart attack with history of coronary
artery disease Paternal grandmother: HTN, died from cancer Paternal grandfather: died in his sleep without any known medical history Siblings:
Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA Brother, 81: HTN Son: Healthy age 48 Daughter: Healthy age 46
