SOAP NOTE TEMPLATE

Demographics

Date: 11/4/2020

Name: Tina Sandler

Age: 29 years old

Occupation: Teacher

Name of Agency: Ihuman

Subjective

CC: “I take my blood pressure at my local pharmacy and when I went it was high”

HPI: 29 y.o AA female G5P2111presents at 31 5/7 weeks’ gestation (third trimester) having

missed visits after being seen at 24 weeks gestation presenting with high blood pressure. At the

drug store her systolic blood pressure was 140’s. Pt unaware how long BP has been elevated

given she does not check her blood pressure regularly at home, in office BP 146/90. Patient also

expressed a 4-pound weight gain this week. 2) Patient also complained of acid reflux while

laying supine. 3) patient complains of headaches are a 3/10 pain non-pulsitile. Headaches

increase when tension is high between patient and husband and last a few hours a few times a

week. Patient has been taking Tylenol to relive headaches.