1
HEENT CAPSTONE
HEENT Capstone
Student
Department of Graduate Nursing, University of Texas at
Arlington College of Nursing and Health Innovation
SOAP Note Form
Family Hx:
Ask patient about
family hx as it
pertains to
current problem.
History of family
hearing loss.
S/ Identifying Information: (initials, age/DOB, gender, reliability)
K.U
85-year-old Female Personal/Social
Hx:
Chief Complaint/RFE: Married
Hard of hearing
Resides in a
retirement
Hx Present Illness: (7 Variables but do not list as such) community
Pt presents with decreased hearing on the right side that began about 2 months ago. The visit
was prompted by the patient’s husband observation regarding her trouble hearing. Patient
states that everything sounds funny and can hear noises but speech isn’t clear and states that
it is worst in her right ear. Patient states she has the most trouble In the dining hall in the
evening. Patient states that her husband and best friend have been having to repeat
themselves when talking to her lately. Patient reports sounds on the right are hollow. The
patient reports that she attempted to treat the problem by using a cotton swab “in case there
was some wax in there”, the patient reports that nothing came out on the swab and it did not
resolve the problem. The patient says that she watches people’s lips when they talk in noisy
restaurants or sometimes just does not listen and that it is frustrating.
CURRENT HEALTH
Medications: Ask patient of current medications taking at home.
Allergies: Ask patients about allergies
Last PE & Screenings: Ask patient of last physical and screening and if she gets regular
screenings and check-ups
Immunization Status: Ask patient if she is up to date on all immunizations? Pneumovax? Flu?
Shingles?
LMP & Birth Control (if applicable) : Patient is 85 and menopausal
PMH
Illnesses & Trauma: Ask patient of any recent illnesses, falls?
[Date]
, 2
HEENT CAPSTONE
Hospitalizations/Surgeries: Ask patient if she has been hospitalized recently. Ask patient about
past surgical history.
OB Hx/Sexual Hx: Ask patient about current sexual practices
Emotional/Psy Hx: admits to having frustration with current situation of not being able to hear
REVIEW OF SYSTEMS
General: document and assess if patient appears clear, in good hygiene, note how the patient
[Date]
HEENT CAPSTONE
HEENT Capstone
Student
Department of Graduate Nursing, University of Texas at
Arlington College of Nursing and Health Innovation
SOAP Note Form
Family Hx:
Ask patient about
family hx as it
pertains to
current problem.
History of family
hearing loss.
S/ Identifying Information: (initials, age/DOB, gender, reliability)
K.U
85-year-old Female Personal/Social
Hx:
Chief Complaint/RFE: Married
Hard of hearing
Resides in a
retirement
Hx Present Illness: (7 Variables but do not list as such) community
Pt presents with decreased hearing on the right side that began about 2 months ago. The visit
was prompted by the patient’s husband observation regarding her trouble hearing. Patient
states that everything sounds funny and can hear noises but speech isn’t clear and states that
it is worst in her right ear. Patient states she has the most trouble In the dining hall in the
evening. Patient states that her husband and best friend have been having to repeat
themselves when talking to her lately. Patient reports sounds on the right are hollow. The
patient reports that she attempted to treat the problem by using a cotton swab “in case there
was some wax in there”, the patient reports that nothing came out on the swab and it did not
resolve the problem. The patient says that she watches people’s lips when they talk in noisy
restaurants or sometimes just does not listen and that it is frustrating.
CURRENT HEALTH
Medications: Ask patient of current medications taking at home.
Allergies: Ask patients about allergies
Last PE & Screenings: Ask patient of last physical and screening and if she gets regular
screenings and check-ups
Immunization Status: Ask patient if she is up to date on all immunizations? Pneumovax? Flu?
Shingles?
LMP & Birth Control (if applicable) : Patient is 85 and menopausal
PMH
Illnesses & Trauma: Ask patient of any recent illnesses, falls?
[Date]
, 2
HEENT CAPSTONE
Hospitalizations/Surgeries: Ask patient if she has been hospitalized recently. Ask patient about
past surgical history.
OB Hx/Sexual Hx: Ask patient about current sexual practices
Emotional/Psy Hx: admits to having frustration with current situation of not being able to hear
REVIEW OF SYSTEMS
General: document and assess if patient appears clear, in good hygiene, note how the patient
[Date]
