HEENT SOAP Documentation
Marc Junchaya
William Paterson University
NUR 6001-808 - Advanced Health Assessment
Dr. Milagros Rojas
May 20, 2026
, Subjective
● Identifying Data & Reliability: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of symptoms in the ear, nose, and throat. Mrs.
Jones is providing all sources of history and provides information freely without any
issues. Mrs. Jones is clear and concise during the interview.
● Chief Complaint: Patient states, “My throat has been sore and itchy, and my nose won’t
stop running”.
● History of Present Illness: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of symptoms in the ear, nose, and throat. Patient
states that symptoms began over a week ago, spontaneously occurring. Patient states the
itching sensation is localized in the throat and eyes and has not disseminated since it
started over a week ago. Patient states that since last week, all symptoms have been
persistent, but notes that symptoms are the worst in the morning. The patient
characterizes her throat pain as four out of ten, stating it just feels sore; the patient also
notes it is painful for her to swallow. Patient notes that when she is swallowing, it
worsens the soreness in her throat. Patient states that throat drops and water help to
provide mild relief for the soreness in her throat. Patient states her eyes are primarily
itchy around the rim, worsening as she scratches; she states she experiences no eye pain.
Patient notes eye itching is only made worse when exposed to cats, which she is allergic
to; the last exposure was a month ago. Patient denies any treatment to alleviate eye
symptoms. Patient states pain from the nose is only external, patient states, “it's raw from
blowing on it so much”. Patient notes copious amounts of clear discharge from her nose.
Patient notes nothing has further aggravated her nasal symptoms but does note excessive
blowing has made her nose raw and painful. Patient denies implementing nasal treatment,
Marc Junchaya
William Paterson University
NUR 6001-808 - Advanced Health Assessment
Dr. Milagros Rojas
May 20, 2026
, Subjective
● Identifying Data & Reliability: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of symptoms in the ear, nose, and throat. Mrs.
Jones is providing all sources of history and provides information freely without any
issues. Mrs. Jones is clear and concise during the interview.
● Chief Complaint: Patient states, “My throat has been sore and itchy, and my nose won’t
stop running”.
● History of Present Illness: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of symptoms in the ear, nose, and throat. Patient
states that symptoms began over a week ago, spontaneously occurring. Patient states the
itching sensation is localized in the throat and eyes and has not disseminated since it
started over a week ago. Patient states that since last week, all symptoms have been
persistent, but notes that symptoms are the worst in the morning. The patient
characterizes her throat pain as four out of ten, stating it just feels sore; the patient also
notes it is painful for her to swallow. Patient notes that when she is swallowing, it
worsens the soreness in her throat. Patient states that throat drops and water help to
provide mild relief for the soreness in her throat. Patient states her eyes are primarily
itchy around the rim, worsening as she scratches; she states she experiences no eye pain.
Patient notes eye itching is only made worse when exposed to cats, which she is allergic
to; the last exposure was a month ago. Patient denies any treatment to alleviate eye
symptoms. Patient states pain from the nose is only external, patient states, “it's raw from
blowing on it so much”. Patient notes copious amounts of clear discharge from her nose.
Patient notes nothing has further aggravated her nasal symptoms but does note excessive
blowing has made her nose raw and painful. Patient denies implementing nasal treatment,
