SOAP NOTE 2 0
SOAP NOTE 2
Sweemy Tank
College of Nursing and Health Innovation, University of Texas at Arlington
NURS 5337-450: Family Clinical Practice 1
Elizabeth Esparza Fuentes, DNP, APRN, FNP-C, ACUE
07/05/2026
, SOAP NOTE 2 1
SOAP Note Form
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
E.H.,4-year-old female here with mom considered a reliable historian Father (alive): healthy
Mother (alive): anemia, asthma
Brother (alive): ADHD
Maternal grandmother (alive):
Hearing loss, depression
Maternal grandfather (alive):
hyperlipidemia, HTN
Paternal grandmother (alive):
HTN, HLD
Paternal grandfather(died): CAD,
HTN, HLD
Personal/Social Hx:
Chief Concern/RFE: E.H. is 4-year-old child that lives
“scabby spot by left eye” with father, mother, her 6-year-old
brother and other siblings 1 and 2
year old. She also has a pet
tortoise. She goes to preschool and
is currently on summer break. Her
grandparents visit often and live
next door. Father has a business.
Mom has a work from home job
and denies any help with food or
living assistance.
Hx Present Illness: (write in paragraph format)
E.H was brought in by mom for worsening scabby spot near the eye that started 5 days ago as a red dot. Lesion has
progressively enlarged and moved closer to the eye over 3 days. Yellow crusting with occasional discharge noted
over the past couple days. Reports using a band-aid to cover the lesion but had a reaction to the adhesive. Mom
reports frequent touching and scratching in the affected area. Denies use of any OTC medication. She reports possible
exposure to make up from the dance recital over the weekend. Denies any pain.
CURRENT HEALTH
Medications: No current medication use.
Allergies: No known allergies
Last PE & Screenings: Last well child check exam on 6/11/2026.
Immunization Status: Up-to-date with all current vaccination: DTaP, Rotavirus, Varicella, Hib, IPV, Hep A, Hep B,
MMR, Pneumococcal conjugate 13V.
LMP & Birth Control (if applicable): N/A
SOAP NOTE 2
Sweemy Tank
College of Nursing and Health Innovation, University of Texas at Arlington
NURS 5337-450: Family Clinical Practice 1
Elizabeth Esparza Fuentes, DNP, APRN, FNP-C, ACUE
07/05/2026
, SOAP NOTE 2 1
SOAP Note Form
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
E.H.,4-year-old female here with mom considered a reliable historian Father (alive): healthy
Mother (alive): anemia, asthma
Brother (alive): ADHD
Maternal grandmother (alive):
Hearing loss, depression
Maternal grandfather (alive):
hyperlipidemia, HTN
Paternal grandmother (alive):
HTN, HLD
Paternal grandfather(died): CAD,
HTN, HLD
Personal/Social Hx:
Chief Concern/RFE: E.H. is 4-year-old child that lives
“scabby spot by left eye” with father, mother, her 6-year-old
brother and other siblings 1 and 2
year old. She also has a pet
tortoise. She goes to preschool and
is currently on summer break. Her
grandparents visit often and live
next door. Father has a business.
Mom has a work from home job
and denies any help with food or
living assistance.
Hx Present Illness: (write in paragraph format)
E.H was brought in by mom for worsening scabby spot near the eye that started 5 days ago as a red dot. Lesion has
progressively enlarged and moved closer to the eye over 3 days. Yellow crusting with occasional discharge noted
over the past couple days. Reports using a band-aid to cover the lesion but had a reaction to the adhesive. Mom
reports frequent touching and scratching in the affected area. Denies use of any OTC medication. She reports possible
exposure to make up from the dance recital over the weekend. Denies any pain.
CURRENT HEALTH
Medications: No current medication use.
Allergies: No known allergies
Last PE & Screenings: Last well child check exam on 6/11/2026.
Immunization Status: Up-to-date with all current vaccination: DTaP, Rotavirus, Varicella, Hib, IPV, Hep A, Hep B,
MMR, Pneumococcal conjugate 13V.
LMP & Birth Control (if applicable): N/A
