NURS 6023-Advanced Assessment and Diagnostic Evaluation
STUDENT NAME: __________________________
Date: ___________________6/30/2026___________________________
SOAP Note
SUBJECTIVE
Chief Complaint Painful urination x 7 days
Ms. Jennifer Smith is a 19-year-old Female patient who presents to clinic today with
sudden painful urination for one week. She reports burning, urgency and frequency
with urination and malodorous that is constant in nature. She reports lower abdominal
pain in the suprapubic region. Denies Hematuria, fever, chills, nausea, vomiting. She
denies lower back pain. No relieving or aggravating factors. Pt reports having to urinate
History of every hour with her pain being a 7 out of 10. She denies any over the counter
Present Illness treatments to relieve symptoms at home. She reports family history of renal calculi.
Patient denies recent or frequent urinary tract infections. Patient denies new sexual
partner.
Review of Systems (Problem-focused)
General Denies fever, fatigue, chills, or weight changes, ill appearing
Skin No rash or lesions reported
Head N/A
Eyes N/A
Ears N/A
Nose N/A
Mouth/Throat N/A
Cardiovascular Denies chest pain or palpitations
Respiratory Denies shortness of breath, difficulty breathing or cough
Abdomen Lower abdominal pain reported, denies diarrhea or constipation, nausea or
vomiting
GU Reports increased frequency, urine odor, and painful urination, denies
hematuria
Lymphatic Denies painful or swollen lymph nodes
MSK Denies flank or back pain
Neurology N/A
Psychiatric Denies anxiety or depression symptoms or mood changes
No significant medical problems
Past Medical History
STUDENT NAME: __________________________
Date: ___________________6/30/2026___________________________
SOAP Note
SUBJECTIVE
Chief Complaint Painful urination x 7 days
Ms. Jennifer Smith is a 19-year-old Female patient who presents to clinic today with
sudden painful urination for one week. She reports burning, urgency and frequency
with urination and malodorous that is constant in nature. She reports lower abdominal
pain in the suprapubic region. Denies Hematuria, fever, chills, nausea, vomiting. She
denies lower back pain. No relieving or aggravating factors. Pt reports having to urinate
History of every hour with her pain being a 7 out of 10. She denies any over the counter
Present Illness treatments to relieve symptoms at home. She reports family history of renal calculi.
Patient denies recent or frequent urinary tract infections. Patient denies new sexual
partner.
Review of Systems (Problem-focused)
General Denies fever, fatigue, chills, or weight changes, ill appearing
Skin No rash or lesions reported
Head N/A
Eyes N/A
Ears N/A
Nose N/A
Mouth/Throat N/A
Cardiovascular Denies chest pain or palpitations
Respiratory Denies shortness of breath, difficulty breathing or cough
Abdomen Lower abdominal pain reported, denies diarrhea or constipation, nausea or
vomiting
GU Reports increased frequency, urine odor, and painful urination, denies
hematuria
Lymphatic Denies painful or swollen lymph nodes
MSK Denies flank or back pain
Neurology N/A
Psychiatric Denies anxiety or depression symptoms or mood changes
No significant medical problems
Past Medical History
