SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: BF Age: 58 Gender:male
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’11 197lbs 146/9 204 19 36.7 c 98% currently Medication:codeine, nausea vomiting
0 no pain
Food: none
Environment:None
History of Present Illness (HPI)
Chief Complaint (CC) “I have been having some troubling chest pain in my chest now and then for CC is a BRIEF statement identifying
the past month” why the patient is here - in the patient’s
own words - for instance "headache",
Onset intermittent onset earlier this month NOT "bad headache for 3 days”.
Location right in the middle of chest non radiating Sometimes a patient has more than
one complaint. For example: If the
Duration episodes lasting only a few minutes patient presents with cough and sore
throat, identify which is the CC and
Characteristics describes pain as chest tightness
which may be an associated symptom
Aggravating Factors exertion, walking up stairs yard work at home
Relieving Factors
rest
Treatment rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Metoprolol 100 mg daily one year Hypertension
, Lipitor 10mg daily hs one year hyperlipedemia
OMega-3 Fish Oil 1200 mg daily unknown unknown
Ibuprofen States takes PRN PRN headache
recommended dose for
adults
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enter text. text. to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypertension stage 2 dx one year ago
Hyperlipidemia diagnosed one year ago
No surgical history
Tdap 10/2014
Influenza this seasons
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Engineer
No tobacco use, Patient married lives with wife and daughter. No ilicit drug use. Has 2-3 drinks on the weekend. Smoke detectors in the house.
State watches fat intake and sodium
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
S: Subjective
Information the patient or patient representative told you
Initials: BF Age: 58 Gender:male
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’11 197lbs 146/9 204 19 36.7 c 98% currently Medication:codeine, nausea vomiting
0 no pain
Food: none
Environment:None
History of Present Illness (HPI)
Chief Complaint (CC) “I have been having some troubling chest pain in my chest now and then for CC is a BRIEF statement identifying
the past month” why the patient is here - in the patient’s
own words - for instance "headache",
Onset intermittent onset earlier this month NOT "bad headache for 3 days”.
Location right in the middle of chest non radiating Sometimes a patient has more than
one complaint. For example: If the
Duration episodes lasting only a few minutes patient presents with cough and sore
throat, identify which is the CC and
Characteristics describes pain as chest tightness
which may be an associated symptom
Aggravating Factors exertion, walking up stairs yard work at home
Relieving Factors
rest
Treatment rest
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Metoprolol 100 mg daily one year Hypertension
, Lipitor 10mg daily hs one year hyperlipedemia
OMega-3 Fish Oil 1200 mg daily unknown unknown
Ibuprofen States takes PRN PRN headache
recommended dose for
adults
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypertension stage 2 dx one year ago
Hyperlipidemia diagnosed one year ago
No surgical history
Tdap 10/2014
Influenza this seasons
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Engineer
No tobacco use, Patient married lives with wife and daughter. No ilicit drug use. Has 2-3 drinks on the weekend. Smoke detectors in the house.
State watches fat intake and sodium
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
