SOAP Note Template
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170
cm
90 kg 142/
82
86 19 101.1 f 99% 7/10 Medication: Penicillin
Food: Denies
Environment: Cats, dust
History of Present Illness (HPI)
Chief Complaint (CC) “I got this scrape on my foot a while ago, and I thought it would heal up on its
own, but now it's looking pretty nasty. And the pain is killing me!”
CC is a BRIEF statement identifying
why the patient is here - in the patient’s
own words - for instance "headache",
NOT "bad headache for 3 days”.
Sometimes a patient has more than
one complaint. For example: If the
patient presents with cough and sore
throat, identify which is the CC and
which may be an associated symptom
Onset 1 week
Location Plantar surface of right foot
Duration Daily
Characteristics She reports that ankle swelling and pain have resolved but that the bottom of
the foot is increasingly painful. The pain is described as “throbbing” and “sharp”
with weight bearing.
Aggravating Factors Weight bearing, walking, standing
Relieving Factors Tramadol
Treatment TJ sought treatment from the emergency department. She received a
prescription for Tramadol, She reports cleaning the wound twice a day and
putting Neosporin and a bandage on the area.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Tramadol 50 mg TID prn Daily for 1 week Pain
Albuterol inhaler 90 mcg/spray 2-3 times per week prn weekly Wheezing
Acetaminophen 500-1000 mg prn Monthly headaches
Ibuprofen 600 mg prn Monthly Menstrual cramps
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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.
S: Subjective
Information the patient or patient representative told you
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Asthma diagnosed at age 2.5, last hospitalized “in high school”, never intubated. Diabetes Mellitus type two, diagnosed age 24. Denies taking
medication for Diabetes, denies keeping track of her glucose. Denies surgies. Immunizations: tetanus: within the past year, Influenza: denies,
Human paoillomavirus: denies, reports all of her childhood shots are up to date abd she received all shots needed for college.
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.
Never married. No Children. Moved out after high school. Currently lives with mother and sister. Moved back in after father died to help mother.
Works at Mid-American Copy and Shipping as a supervisor. 32 hours a week. She is a part time college student; she has 2 semesters left in order
to earn her bachelor's degree in accounting. She plans to get a job at an accounting firm after graduation. She has a car and a cell phone. She has
health insurance through work but is unsure of what it covers. She likes to go to bar and clubs with her friends. She like to watch tv, spend time with
friends, attend bible study, volunteer at church, and dance. She has a strong support system. She generally gets stressed when she has too much
to do but currently reports no stressors. Reports smoking marijuana at age 15 until age 21. Denies any other drug use. Reports occasional alcohol
consumption 2-3 times per month. Reports only a "few" drinks when she goes out. She denies driving while intoxicated. Reports drinking 4 diet
sodas a day. Denies foreign travel. Denies pets. Denies current relationship. Last relationship 2 years ago. Future plans to live independently, have
a relationship, family, and job growth. Safety: Has smoke detectors in the house, wears a seat belt, does not ride a bike, occasionally wears
sunscreen, gun lucked up in mothers’ room.
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
pertinent.
• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
Constitutional Skin HEENT
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