NU 561 - Week 8 Focus SOAP Note Latest Update 2025/2026
Doc Contains
➢Subjective Data, Objective Data:
➢History of Present Illness:
➢Vital Signs:
➢Physical Assessment Findings:
➢Medications
➢Referral
➢Follow-up
➢Routine Health Maintenance:
➢ References
Focus SOAP Note 3
Molly Bre…
Sacred Heart University
Dr. Wendy Cantrell
NU 561
March 1, 2025
, Focus SOAP Note 3 2
SOAP Note
NU 561
Patient Initials _KM__
Subjective Data:
Chief Compliant: Patient states “cough with yellow phlegm, runny nose, body aches, headache,
and fatigue for 1 day.”
History of Present Illness: KM, is a 22-year-old female with the onset of symptoms of cough
with yellow phlegm, body aches, headache, and fatigue for one day. Patient states her headache
is in the middle of her forehead and feels like a lot of pressure, her body aches are all over her
body but predominantly in her back, and her throat feels irritated when she coughs. Her
headaches are intermittent, her body aches are constant, and her throat hurts only when she
coughs. She does not state if anything aggravates the symptoms, but she took Tylenol once to
help with symptom alleviation, and only had mild relief. Patient KM has not tried any other
treatments at this time.
PMH/Medical/Surgical History:
PMH:
• None
Medications:
• No prescription medications, herbal remedies or supplements taken at this time Allergies:
• NKDA
PSHx:
• None
Immunizations: