NR509 Shadow Health SOAP Note Template | A+ Rated | Nursing Documentation Guide

Nr509_Shadow_Health_Soap_Note_Template.pdf (1).pdf| Full Q&A | 2026/2027


NR509 Shadow Health SOAP Note Template
NR509 Shadow Health SOAP Note Template
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
SOAP Note Template




Initials: Click or tap here to enter text.Age: Click or tap here to enter text.Gender: Click or tap here to enter
text.HeightWeightBPHRRRTempSPO2PainAllergiesClick or tap here to enter text.Click or tap here to enter text.Click or
tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap
here to enter text.Choose an item.Medication: Click or tap here to enter text.
Food: Click or tap here to enter text.
Environment: Click or tap here to enter text.
History of Present Illness (HPI) NR509 Shadow Health SOAP Note TemplateChief Complaint (CC)Click or tap
here to enter text.CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance
“headache”, NOT “bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the
patient presents with cough and sore throat, identify which is the CC and which may be an associated
symptomOnsetClick or tap here to enter text.LocationClick or tap here to enter text.DurationClick or tap here to enter
text.CharacteristicsClick or tap here to enter text.Aggravating FactorsClick or tap here to enter text.Relieving FactorsClick
or tap here to enter text.TreatmentClick or tap here to enter text.Current Medications: Include dosage, frequency, length
of time used and reason for use; also include OTC or homeopathic products.Medication
(Rx, OTC, or Homeopathic)
DosageFrequencyLength of Time UsedReason for UseClick or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter
text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here 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.




Click or tap here to enter text.
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.
Click or tap here to enter text.


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.
Click or tap here to enter text.

, Nr509_Shadow_Health_Soap_Note_Template.pdf (1).pdf| Full Q&A | 2026/2027


Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the
box next to each positive symptom and provide additional details.ConstitutionalSkinHEENT☐Fatigue Click or tap here to
enter text.
☐Weakness Click or tap here to enter text.

☐Fever/Chills Click or tap here to enter text.

☐Weight Gain Click or tap here to enter text.

☐Weight Loss Click or tap here to enter text.

☐Trouble Sleeping Click or tap here to enter text.

☐Night Sweats Click or tap here to enter text.

☐Other:

Click or tap here to enter text.
☐Itching Click or tap here to enter text.

☐Rashes Click or tap here to enter text.

☐Nail Changes Click or tap here to enter text.

☐Skin Color Changes Click or tap here to enter text.

☐Other:

Click or tap here to enter text.


☐Diplopia Click or tap here to enter text.

☐Eye Pain Click or tap here to enter text.

☐Eye redness Click or tap here to enter text.

☐Vision changes Click or tap here to enter text.

☐Photophobia Click or tap here to enter text.

☐Eye discharge Click or tap here to enter text.



☐Earache Click or tap here to enter text.

☐Tinnitus Click or tap here to enter text.

☐Epistaxis Click or tap here to enter text.

☐Vertigo Click or tap here to enter text.

☐Hearing Changes Click or tap here to enter text.



☐Hoarseness Click or tap here to enter text.

☐Oral Ulcers Click or tap here to enter text.

☐Sore Throat Click or tap here to enter text.

☐Congestion Click or tap here to enter text.

☐Rhinorrhea Click or tap here to enter text.

☐Other: