SOAP Note Template for Clinical Check Off in CP1 & CP2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
P. J, 12 year old female, DOB 7/29/2012, mother present as primary historian
No significant family
history, mother and
father healthy.
Personal/Social Hx:
Chief Complaint/RFE:
“throat pain and fever for 3 days” 3rd grade in
elementary school
Hx Present Illness: (write in paragraph format)
P. J a 12 year old female presents to the clinic with her mother with complaint of throat pain and fever that started 3 days ago.
Patient describes the throat pain as constant, sore and burning. The pain is worse with swallowing. Mother states she has
given patient Ibuprofen for pain and fever with mild improvement in fever but did little for the throat pain. Mother reports she has
heard of other children in her daughter’s class being sick with similar symptoms.
CURRENT HEALTH
Medications: Ibuprofen as needed per directions on bottle
Allergies: Penicillin
Last PE & Screenings: up to date
Immunization Status: up to date, including flu and covid vaccines
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, LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: none
Hospitalizations/Surgeries: none
OB Hx/Sexual Hx: n/a
Emotional/Psych Hx: none
REVIEW OF SYSTEMS
General fever, acutely ill
Nutrition decreased PO intake due to pain with swallowing
Skin/Hair/Nails deferred
HEENT Head: denies headache, Eyes-reports clear drainage, Nose-reports clear drainage, denies congestion and sinus pressure, Throat-
reports constant pain
Breasts deferred
Respiratory Denies cough or shortness of breath
CV/peripheral vascular Denies chest pain or palpitations
GI Reports diarrhea, denies nausea and vomiting
GU deferred
MSK Denies body aches
Psych deferred
Neuro no neuro changes noted by mother
Lymph/Heme/Endocrine deferred
O/ Physical Exam: T: 103.3 P: 76 R: 20 BP: 102/54 HT: 57 inches WT: 75lbs BMI: 16.2
General appears acutely ill, friendly
Skin warm to touch
Head normocephalic
EENT Eyes: conjunctiva clear, clear drainage present. Ears: no erythema to tympanic membranes bilaterally. Nose: no nasal erythema, clear
discharge present. Non tender frontal/maxillary sinuses. Throat: bilateral tonsillar enlargement with exudate, pharyngeal erythema
Neck trachea midline, normal range of motion
Breasts/Chest deferred
Lungs clear to all lobes, no shortness of breath or cough present
This study source was downloaded by 100000900412927 from CourseHero.com on 10-29-2025 15:50:12 GMT -05:00
https://www.coursehero.com/file/250604841/SOAP-note-3docx/
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
P. J, 12 year old female, DOB 7/29/2012, mother present as primary historian
No significant family
history, mother and
father healthy.
Personal/Social Hx:
Chief Complaint/RFE:
“throat pain and fever for 3 days” 3rd grade in
elementary school
Hx Present Illness: (write in paragraph format)
P. J a 12 year old female presents to the clinic with her mother with complaint of throat pain and fever that started 3 days ago.
Patient describes the throat pain as constant, sore and burning. The pain is worse with swallowing. Mother states she has
given patient Ibuprofen for pain and fever with mild improvement in fever but did little for the throat pain. Mother reports she has
heard of other children in her daughter’s class being sick with similar symptoms.
CURRENT HEALTH
Medications: Ibuprofen as needed per directions on bottle
Allergies: Penicillin
Last PE & Screenings: up to date
Immunization Status: up to date, including flu and covid vaccines
This study source was downloaded by 100000900412927 from CourseHero.com on 10-29-2025 15:50:12 GMT -05:00
https://www.coursehero.com/file/250604841/SOAP-note-3docx/
, LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: none
Hospitalizations/Surgeries: none
OB Hx/Sexual Hx: n/a
Emotional/Psych Hx: none
REVIEW OF SYSTEMS
General fever, acutely ill
Nutrition decreased PO intake due to pain with swallowing
Skin/Hair/Nails deferred
HEENT Head: denies headache, Eyes-reports clear drainage, Nose-reports clear drainage, denies congestion and sinus pressure, Throat-
reports constant pain
Breasts deferred
Respiratory Denies cough or shortness of breath
CV/peripheral vascular Denies chest pain or palpitations
GI Reports diarrhea, denies nausea and vomiting
GU deferred
MSK Denies body aches
Psych deferred
Neuro no neuro changes noted by mother
Lymph/Heme/Endocrine deferred
O/ Physical Exam: T: 103.3 P: 76 R: 20 BP: 102/54 HT: 57 inches WT: 75lbs BMI: 16.2
General appears acutely ill, friendly
Skin warm to touch
Head normocephalic
EENT Eyes: conjunctiva clear, clear drainage present. Ears: no erythema to tympanic membranes bilaterally. Nose: no nasal erythema, clear
discharge present. Non tender frontal/maxillary sinuses. Throat: bilateral tonsillar enlargement with exudate, pharyngeal erythema
Neck trachea midline, normal range of motion
Breasts/Chest deferred
Lungs clear to all lobes, no shortness of breath or cough present
This study source was downloaded by 100000900412927 from CourseHero.com on 10-29-2025 15:50:12 GMT -05:00
https://www.coursehero.com/file/250604841/SOAP-note-3docx/
