NURS 624(10.1 SOAP Note.)
S.O.A.P. Note Template
Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Patient demographics
Primary care office visit
Sick visit
Assignment 10.1 SOAP Note
Subjective History
Chief Complaint
What brought you here today…(such as a headache)
Stomach ache with burning, hx 2 months
History of Present Illness
Chronological order of events, state of health before onset of CC, must include
OLDCARTS (Onset, Location, Duration, Character, Aggravating/associated factors,
Relieving factors, Temporal factors – other things going on, Severity) in paragraph form
A 35-year-old male presents with a 1–2 month history of a stomach ache and burning
off and on. He thinks the pain worsens after eating and on the weekends. He is married
with three children and works in the IT department of a local hospital system.
Past Medical History
Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current
medications
S.O.A.P. Note Template
Case ID#:
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Patient demographics
Primary care office visit
Sick visit
Assignment 10.1 SOAP Note
Subjective History
Chief Complaint
What brought you here today…(such as a headache)
Stomach ache with burning, hx 2 months
History of Present Illness
Chronological order of events, state of health before onset of CC, must include
OLDCARTS (Onset, Location, Duration, Character, Aggravating/associated factors,
Relieving factors, Temporal factors – other things going on, Severity) in paragraph form
A 35-year-old male presents with a 1–2 month history of a stomach ache and burning
off and on. He thinks the pain worsens after eating and on the weekends. He is married
with three children and works in the IT department of a local hospital system.
Past Medical History
Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current
medications
