10/11/23, 6:59 PM Comprehensive SOAP Exemplar
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include.
Remember that Nurse Practitioners treat patients in a holistic manner and your
SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female
who presents today with a productive cough x 3 weeks and fever for the last three
days. She reported that the “cold feels like it is descending into her chest”. The
cough is nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has associated symptoms of
dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She
has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but
returns after the medication wears off. She rated the severity of her symptom
discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d
with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
© 2019 Walden University Page 1 of 4
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug
use.
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Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include.
Remember that Nurse Practitioners treat patients in a holistic manner and your
SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female
who presents today with a productive cough x 3 weeks and fever for the last three
days. She reported that the “cold feels like it is descending into her chest”. The
cough is nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has associated symptoms of
dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She
has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but
returns after the medication wears off. She rated the severity of her symptom
discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d
with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
© 2019 Walden University Page 1 of 4
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug
use.
about:blank 1/4
