WGU D117 | ADVANCED HEALTH ASSESSMENT | 2026–2027
SOAP Notes & Clinical Documentation Workbook
16 fictional encounter templates, model reasoning, and documentation quality
checklists
.
SOAP documentation rule set
• S: patient-reported chief concern, chronology, pertinent review of systems, history, medications, allergies and
functional effect.
• O: actual measured vital signs and examination findings; no invented negatives or templated normal systems.
• A: concise problem representation, prioritized differential, evidence for/against important diagnoses, documented
uncertainty.
• P: testing/referrals when indicated, care communication, follow-up responsibility, specific return precautions and
shared plan.
• Never copy a hypothetical note into a real chart or submit it as personal clinical experience.
Worked and practice clinical notes
SOAP Case 01: Acute chest discomfort
Case data (fictional): 54-year-old with 40 minutes of heavy substernal discomfort, sweating and nausea. BP 90/56,
pulse 112, pale and diaphoretic.
S — Subjective: 54-year-old with 40 minutes of heavy substernal discomfort, sweating and nausea
O — Objective: BP 90/56, pulse 112, pale and diaphoretic
A — Assessment: Potential acute coronary syndrome or other life-threatening cardiopulmonary condition; preserve
uncertainty and identify relevant differentials.
P — Plan: Stop routine assessment and trigger emergency stabilization and evaluation; record symptom onset and vital
signs. Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 02: Severe sudden headache
Case data (fictional): 43-year-old describes a headache that reached peak severity in seconds. Alert with initially
nonfocal brief neurologic exam.
S — Subjective: __________________________________________________________________________
____________________________________________________________________________________________
O — Objective: __________________________________________________________________________
____________________________________________________________________________________________
A — Assessment and prioritized differential:
__________________________________________________________________________
____________________________________________________________________________________________
P — Investigations, communication, follow-up and safety-net:
__________________________________________________________________________
____________________________________________________________________________________________
INDEPENDENT STUDY RESOURCE • NOT A WGU ASSESSMENT
, WGU D117 | ADVANCED HEALTH ASSESSMENT | 2026–2027
Self-check / expected priority: Subarachnoid hemorrhage and other secondary thunderclap headache causes.
Urgent emergency evaluation despite an initially nonfocal exam; obtain key timing and accompanying symptoms.
SOAP Case 03: Flank pain with fever
Case data (fictional): 29-year-old has dysuria for three days followed by fever, vomiting, and unilateral flank pain. T 39.0
C, pulse 116, flank tenderness.
S — Subjective: 29-year-old has dysuria for three days followed by fever, vomiting, and unilateral flank pain
O — Objective: T 39.0 C, pulse 116, flank tenderness
A — Assessment: Upper urinary infection with possible systemic involvement; obstruction is a competing concern;
preserve uncertainty and identify relevant differentials.
P — Plan: Assess stability and arrange urgent evaluation with appropriate urine studies and further testing as indicated.
Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 04: Dizziness and dark stools
Case data (fictional): 67-year-old reports black stools, fatigue, and near-syncope. BP 94/60, pulse 115, pale
conjunctivae.
S — Subjective: 67-year-old reports black stools, fatigue, and near-syncope
O — Objective: BP 94/60, pulse 115, pale conjunctivae
A — Assessment: Possible gastrointestinal bleeding with symptomatic volume loss; preserve uncertainty and identify
relevant differentials.
P — Plan: Prioritize hemodynamic assessment and urgent referral; document stool history and medication exposures.
Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 05: Dyspnea with unilateral swelling
Case data (fictional): 39-year-old reports acute shortness of breath and new painful swollen calf after immobility. Pulse
118, RR 27, oxygen saturation 92% on room air.
S — Subjective: __________________________________________________________________________
____________________________________________________________________________________________
O — Objective: __________________________________________________________________________
____________________________________________________________________________________________
A — Assessment and prioritized differential:
__________________________________________________________________________
____________________________________________________________________________________________
P — Investigations, communication, follow-up and safety-net:
__________________________________________________________________________
____________________________________________________________________________________________
Self-check / expected priority: Possible venous thromboembolism and pulmonary embolism. Escalate urgently;
avoid falsely excluding serious illness based on any single examination finding.
INDEPENDENT STUDY RESOURCE • NOT A WGU ASSESSMENT
SOAP Notes & Clinical Documentation Workbook
16 fictional encounter templates, model reasoning, and documentation quality
checklists
.
SOAP documentation rule set
• S: patient-reported chief concern, chronology, pertinent review of systems, history, medications, allergies and
functional effect.
• O: actual measured vital signs and examination findings; no invented negatives or templated normal systems.
• A: concise problem representation, prioritized differential, evidence for/against important diagnoses, documented
uncertainty.
• P: testing/referrals when indicated, care communication, follow-up responsibility, specific return precautions and
shared plan.
• Never copy a hypothetical note into a real chart or submit it as personal clinical experience.
Worked and practice clinical notes
SOAP Case 01: Acute chest discomfort
Case data (fictional): 54-year-old with 40 minutes of heavy substernal discomfort, sweating and nausea. BP 90/56,
pulse 112, pale and diaphoretic.
S — Subjective: 54-year-old with 40 minutes of heavy substernal discomfort, sweating and nausea
O — Objective: BP 90/56, pulse 112, pale and diaphoretic
A — Assessment: Potential acute coronary syndrome or other life-threatening cardiopulmonary condition; preserve
uncertainty and identify relevant differentials.
P — Plan: Stop routine assessment and trigger emergency stabilization and evaluation; record symptom onset and vital
signs. Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 02: Severe sudden headache
Case data (fictional): 43-year-old describes a headache that reached peak severity in seconds. Alert with initially
nonfocal brief neurologic exam.
S — Subjective: __________________________________________________________________________
____________________________________________________________________________________________
O — Objective: __________________________________________________________________________
____________________________________________________________________________________________
A — Assessment and prioritized differential:
__________________________________________________________________________
____________________________________________________________________________________________
P — Investigations, communication, follow-up and safety-net:
__________________________________________________________________________
____________________________________________________________________________________________
INDEPENDENT STUDY RESOURCE • NOT A WGU ASSESSMENT
, WGU D117 | ADVANCED HEALTH ASSESSMENT | 2026–2027
Self-check / expected priority: Subarachnoid hemorrhage and other secondary thunderclap headache causes.
Urgent emergency evaluation despite an initially nonfocal exam; obtain key timing and accompanying symptoms.
SOAP Case 03: Flank pain with fever
Case data (fictional): 29-year-old has dysuria for three days followed by fever, vomiting, and unilateral flank pain. T 39.0
C, pulse 116, flank tenderness.
S — Subjective: 29-year-old has dysuria for three days followed by fever, vomiting, and unilateral flank pain
O — Objective: T 39.0 C, pulse 116, flank tenderness
A — Assessment: Upper urinary infection with possible systemic involvement; obstruction is a competing concern;
preserve uncertainty and identify relevant differentials.
P — Plan: Assess stability and arrange urgent evaluation with appropriate urine studies and further testing as indicated.
Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 04: Dizziness and dark stools
Case data (fictional): 67-year-old reports black stools, fatigue, and near-syncope. BP 94/60, pulse 115, pale
conjunctivae.
S — Subjective: 67-year-old reports black stools, fatigue, and near-syncope
O — Objective: BP 94/60, pulse 115, pale conjunctivae
A — Assessment: Possible gastrointestinal bleeding with symptomatic volume loss; preserve uncertainty and identify
relevant differentials.
P — Plan: Prioritize hemodynamic assessment and urgent referral; document stool history and medication exposures.
Include indicated tests, patient communication, explicit return precautions, and documented follow-up.
Learning check: Identify any missing history, examination findings or diagnostic evidence before using this as a real
clinical note. The note is an illustrative fiction, not a complete patient record.
SOAP Case 05: Dyspnea with unilateral swelling
Case data (fictional): 39-year-old reports acute shortness of breath and new painful swollen calf after immobility. Pulse
118, RR 27, oxygen saturation 92% on room air.
S — Subjective: __________________________________________________________________________
____________________________________________________________________________________________
O — Objective: __________________________________________________________________________
____________________________________________________________________________________________
A — Assessment and prioritized differential:
__________________________________________________________________________
____________________________________________________________________________________________
P — Investigations, communication, follow-up and safety-net:
__________________________________________________________________________
____________________________________________________________________________________________
Self-check / expected priority: Possible venous thromboembolism and pulmonary embolism. Escalate urgently;
avoid falsely excluding serious illness based on any single examination finding.
INDEPENDENT STUDY RESOURCE • NOT A WGU ASSESSMENT
