SOAP NOTES TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: DR:
Age: 8 years old
Gender: Male
Height: 4’2”
Weight: 90lbs
BP: 120/91
HR: 100
RR: 28
FVC: 3.91
FEV1: 3.15
FEV1/FVC: 80.5%
Temp: 37.2C
SPO2: 96%
Pain (1-10): 3
Allergies
Medication: NKDA
Food: No known food allergies
Environment: No known environmental allergies
History of Present Illness (HPI)
Chief Complaint (CC): Cough
Onset: 5 days ago
Location: Chest
Duration: Frequent (every couple of minutes without trigger noted)
Characteristics: Wet, productive with clear sputum
Aggravating Factors: Unknown triggers
Relieving Factors: Cough medicine alleviated the cough for a short amount of time
Treatment: Cough syrup today
Current Medications
Medication Dosage Frequency Length of Time Reason for Use
, SOAP NOTES TEMPLATE
Used
Kids Multivitamin Recommended Daily Unknown Health maintenance
Gummies dosing
Cough Syrup Recommended PRN Unknown Cough treatment
dosing
Past Medical History (PMHx)—
Danny is an 8-year-old male that denies any history of allergies to medications, foods, seasonal, latex or
environmental agents. He reports having frequent colds and being diagnosed with pneumonia last year.
He takes a daily dose of children’s multivitamin gummies as well as PRN doses of cough syrup to treat
episodes of coughing. He reports that his immunizations are up to date and denies any other history of
major illnesses (including asthma), hospitalizations, or surgeries.
Social History (Soc Hx)—
Danny is a 3rd grade student with a reported history of missing school for two weeks last year due to
pneumonia. He lives with his mother and father and is cared for by his grandmother while his parents
are working. English is the primary language spoken in the home with Spanish as an alternate language
utilized.
Family History (Fam Hx)—
Danny’s mother has type II diabetes, hypertension, hypercholesterolemia, spinal stenosis, and is obese
Danny’s father is a smoker (cigars), and has hypertension, hypercholesterolemia, as well as a childhood
history of asthma
Danny’s grandparent’s history:
Maternal—
Grandmother: type II diabetes and hypertension
Grandfather: Smoker and eczema
Paternal—
Grandmother: died in a car accident at 52 years of age
Grandfather: No known history
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Symptom Details
S: Subjective
Information the patient or patient representative told you.
Initials: DR:
Age: 8 years old
Gender: Male
Height: 4’2”
Weight: 90lbs
BP: 120/91
HR: 100
RR: 28
FVC: 3.91
FEV1: 3.15
FEV1/FVC: 80.5%
Temp: 37.2C
SPO2: 96%
Pain (1-10): 3
Allergies
Medication: NKDA
Food: No known food allergies
Environment: No known environmental allergies
History of Present Illness (HPI)
Chief Complaint (CC): Cough
Onset: 5 days ago
Location: Chest
Duration: Frequent (every couple of minutes without trigger noted)
Characteristics: Wet, productive with clear sputum
Aggravating Factors: Unknown triggers
Relieving Factors: Cough medicine alleviated the cough for a short amount of time
Treatment: Cough syrup today
Current Medications
Medication Dosage Frequency Length of Time Reason for Use
, SOAP NOTES TEMPLATE
Used
Kids Multivitamin Recommended Daily Unknown Health maintenance
Gummies dosing
Cough Syrup Recommended PRN Unknown Cough treatment
dosing
Past Medical History (PMHx)—
Danny is an 8-year-old male that denies any history of allergies to medications, foods, seasonal, latex or
environmental agents. He reports having frequent colds and being diagnosed with pneumonia last year.
He takes a daily dose of children’s multivitamin gummies as well as PRN doses of cough syrup to treat
episodes of coughing. He reports that his immunizations are up to date and denies any other history of
major illnesses (including asthma), hospitalizations, or surgeries.
Social History (Soc Hx)—
Danny is a 3rd grade student with a reported history of missing school for two weeks last year due to
pneumonia. He lives with his mother and father and is cared for by his grandmother while his parents
are working. English is the primary language spoken in the home with Spanish as an alternate language
utilized.
Family History (Fam Hx)—
Danny’s mother has type II diabetes, hypertension, hypercholesterolemia, spinal stenosis, and is obese
Danny’s father is a smoker (cigars), and has hypertension, hypercholesterolemia, as well as a childhood
history of asthma
Danny’s grandparent’s history:
Maternal—
Grandmother: type II diabetes and hypertension
Grandfather: Smoker and eczema
Paternal—
Grandmother: died in a car accident at 52 years of age
Grandfather: No known history
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Symptom Details
