S.O.A.P. Note Template practium 3

S.O.A.P. Note Template Case ID#: Practicum SOAP Note #3 Basic Information Name: J.K Gender : Female Age :77 year olds Status: Established patient Subjective History Chief Complaint “I’m just here for my 3 month follow up” History of Present Illness 77 year old adult female presents to the office for a three month follow up appointment. Patient states that she is feeling great and currently has no health concerns or complaints at this time. Past Medical History Adult illnesses: COPD d/t tobacco use, hypothyroidism, osteoarthritis, hypercholesterolemia, and insomnia, hypertension, and basal cell carcinoma in remission Childhood illnesses: No assessed at this time Immunizations: Patient is up to date on all vaccines. Received the flu shot in September 2020. Patient has alreadt received both doses of the COVID-19 vaccine Surgeries: Basal cell carcinoma removal in 2017 Allergies: Lamisil- Rash Current medications: Synthroid 12.5mcg PO QD, Lisinopril 5mg PO QD, ASA 81mg PO QD, Simvastatin 20mg PO QD Health Promotion goals: To continue preventative follow-ups as needed Psychiatric: Patient denies any symptoms of depression, anxiety, and thoughts of suicide.