Running head: ADULT SOAP NOTE 1
Adult SOAP note
Clara Garza
University of Texas at Arlington
College of Nursing and Health Innovation
in partial fulfillment of the requirements of
NURS 5220 Advanced Health Assessment
Sara Moore, DNP, APRN, PNP-BC, CPNP-AC, NNP
, ADULT SOAP NOTE 2
June 15, 2019
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
K.U. is an 85 year-old married female, presented to the clinic on K.U., will you
06/15/2019. The history is obtained from the patient, and she is tell me about
considered to be a reliable historian. your family
history to include
any medical
information. Are
your parents and
siblings still
living? Did they
have any medical
conditions?
Personal/Social
Hx:
Chief Complaint/RFE: Married, residing
“My husband says he has to repeat himself too many times when he talks in a retirement
to me and that I should get my hearing checked.” community. How
long have you
and your husband
been married?
How many
children did you
and your spouse
have?
Where did you
grow up? Where
did you go to
school? Were
you ever
employed? When
did you retire?
Are you and your
spouse still
sexually active?
Do you get
regular exercise?
Do you have any
pets? Do you
Hx Present Illness: travel often?
This patient is an 85 year-old female with unknown medical history presented to clinic on
6/15/2019 with deceased hearing on right side. Visit encouraged by spouse due to trouble
Adult SOAP note
Clara Garza
University of Texas at Arlington
College of Nursing and Health Innovation
in partial fulfillment of the requirements of
NURS 5220 Advanced Health Assessment
Sara Moore, DNP, APRN, PNP-BC, CPNP-AC, NNP
, ADULT SOAP NOTE 2
June 15, 2019
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
K.U. is an 85 year-old married female, presented to the clinic on K.U., will you
06/15/2019. The history is obtained from the patient, and she is tell me about
considered to be a reliable historian. your family
history to include
any medical
information. Are
your parents and
siblings still
living? Did they
have any medical
conditions?
Personal/Social
Hx:
Chief Complaint/RFE: Married, residing
“My husband says he has to repeat himself too many times when he talks in a retirement
to me and that I should get my hearing checked.” community. How
long have you
and your husband
been married?
How many
children did you
and your spouse
have?
Where did you
grow up? Where
did you go to
school? Were
you ever
employed? When
did you retire?
Are you and your
spouse still
sexually active?
Do you get
regular exercise?
Do you have any
pets? Do you
Hx Present Illness: travel often?
This patient is an 85 year-old female with unknown medical history presented to clinic on
6/15/2019 with deceased hearing on right side. Visit encouraged by spouse due to trouble
