10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM health
SOAP Note Template
S:
Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain
Rating Allergies (and reaction)
170 88k 139 82 16 98.9 99% Medication: penicillin
cm g / hives. Food: none
BMI: 87 Environment: cats respiratory difficulty.
30.5
History of Present Illness (HPI)
Chief Complaint (CC) Headache and neck pain after fender-bender. CC is a BRIEF statement identifying
Onset Accident one week ago symptoms occurred 2 why the patient is here - in the
days after patient’s own words - for instance
Location Parking lot "headache", NOT "bad headache for
3 days”. Sometimes a patient has
Duration 1-2 hours more than one complaint. For
Characteristics Dull ache not cluster or cyclic or sharp. example: If the patient presents with
cough and
Aggravating Head or neck sore throat, identify which is the CC
Factors movement.
Relieving Factors Rest and Tylenol and which may be an associated
Treatment Rest and Tylenol until further symptom
evaluation
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of
Dosage Frequency Time Reason for Use
(Rx, OTC, or Homeopathic)
Used
about:blan 1/
k 40
,10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM Tylenol 2 tabs regular strength health
Once daily At onset of Head and neck pain post
pain 5 days fender bender.
Proventil inhaler Two 90 mcg puffs PRN Since 2.5 Asthma exacerbation
years old
Flovent 2 puffs of 44 mcg BID Unknown asthma
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here to enter text.
about:blan 2/
k 40
,10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM health
enter text. text.to enter text.
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about:blan 3/
k 40
, 10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM health
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.
Immunization up to date. Last tetanus booster was received previous year. Currently headaches and neck pain. Past major
illnesses include Asthma, & diabetes. Previous hospitalizations for asthma and recent foot injury/infection. No prior surgeries.
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.
Supervisor at mid-American copy and ship since high
school. Hangs out at bars and clubs on free time.
The patient is single with no kids
Currently non-sexually active for two years. Her relationships are
heterosexual. When dating she is monogamous. She has had 3 partners
in her lifetime.
Non-smoker \ occasional drinker. With History of marijuana us, but denies further drug or marijuana use.
The Patient is involved in her Baptist church. They provide support and community for each other. The patient helps
at events throughout the week.
The patient is currently pursuing her bachelor’s in accounting.
Patient uses seat belts occasionally and has working smoke detectors in house.
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.
about:blan 4/
k 40
PM health
SOAP Note Template
S:
Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain
Rating Allergies (and reaction)
170 88k 139 82 16 98.9 99% Medication: penicillin
cm g / hives. Food: none
BMI: 87 Environment: cats respiratory difficulty.
30.5
History of Present Illness (HPI)
Chief Complaint (CC) Headache and neck pain after fender-bender. CC is a BRIEF statement identifying
Onset Accident one week ago symptoms occurred 2 why the patient is here - in the
days after patient’s own words - for instance
Location Parking lot "headache", NOT "bad headache for
3 days”. Sometimes a patient has
Duration 1-2 hours more than one complaint. For
Characteristics Dull ache not cluster or cyclic or sharp. example: If the patient presents with
cough and
Aggravating Head or neck sore throat, identify which is the CC
Factors movement.
Relieving Factors Rest and Tylenol and which may be an associated
Treatment Rest and Tylenol until further symptom
evaluation
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of
Dosage Frequency Time Reason for Use
(Rx, OTC, or Homeopathic)
Used
about:blan 1/
k 40
,10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM Tylenol 2 tabs regular strength health
Once daily At onset of Head and neck pain post
pain 5 days fender bender.
Proventil inhaler Two 90 mcg puffs PRN Since 2.5 Asthma exacerbation
years old
Flovent 2 puffs of 44 mcg BID Unknown asthma
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.
about:blan 2/
k 40
,10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM health
enter text. text.to enter text.
Click or tap here to enter text.Click or tap here to Click or tap here to enterClick or tap here Click or tap here to enter text.
about:blan 3/
k 40
, 10/22/24, 1:25 NR 509 SOAP Note w eek 3 Neuro shadow
PM health
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.
Immunization up to date. Last tetanus booster was received previous year. Currently headaches and neck pain. Past major
illnesses include Asthma, & diabetes. Previous hospitalizations for asthma and recent foot injury/infection. No prior surgeries.
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.
Supervisor at mid-American copy and ship since high
school. Hangs out at bars and clubs on free time.
The patient is single with no kids
Currently non-sexually active for two years. Her relationships are
heterosexual. When dating she is monogamous. She has had 3 partners
in her lifetime.
Non-smoker \ occasional drinker. With History of marijuana us, but denies further drug or marijuana use.
The Patient is involved in her Baptist church. They provide support and community for each other. The patient helps
at events throughout the week.
The patient is currently pursuing her bachelor’s in accounting.
Patient uses seat belts occasionally and has working smoke detectors in house.
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.
about:blan 4/
k 40
