SOAP NOTE
\nName: Date: Time:
\nAge: Sex:
\nSUBJECTIVE
\nCC:
\nReason given by the patient for seeking medical care \u201cin quotes\u201d
\nHPI:
\nDescribe the course of the patient\u2019s illness, including when it began, character of symptoms, location
\nwhere the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
\nrelated diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
\nMedications: (list with reason for med )
\nPMH
\nAllergies:
\nMedication Intolerances:
\nChronic Illnesses\/Major traumas
\nHospitalizations\/Surgeries
\n\u201cHave you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
\ndisease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.\u201d
\nFamily History
\nDoes your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
\nlung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
\nSocial History
\nEducation level, occupational history, current living situation\/partner\/marital status, substance use\/abuse,
\nETOH, tobacco, marijuana. Safety status
\nROS
\nGeneral
\nWeight change, fatigue, fever, chills, night sweats,
\nenergy level
\nCardiovascular
\nChest pain, palpitations, PND, orthopnea, edema
\nSkin
\nDelayed healing, rashes, bruising, bleeding or skin
\ndiscolorations, any changes in lesions or moles
\nRespiratory
\nCough, wheezing, hemoptysis, dyspnea, pneumonia
\nhx, TB
\nEyes
\nCorrective lenses, blurring, visual changes of any
\nkind
\nGastrointestinal
\nAbdominal pain, N\/V\/D, constipation, hepatitis,
\nhemorrhoids, eating disorders, ulcers, black tarry
\nstools
\nEars
\nEar pain, hearing loss, ringing in ears, discharge
\nGenitourinary\/Gynecological
\nUrgency, frequency burning, change in color of
\nurine.
\nContraception, sexual activity, STDS
\nFe: last pap, breast, mammo, menstrual
\ncomplaints, vaginal discharge, pregnancy hx
\nMale: prostate, PSA, urinary complaints
\nNose\/Mouth\/Throat
\nSinus problems, dysphagia, nose bleeds or
\ndischarge, dental disease, hoarseness, throat pain
\nMusculoskeletal
\nBack pain, joint swelling, stiffness or pain, fracture
\nhx, osteoporosis
\nBreast
\nSBE, lumps, bumps or changes
\nNeurological
\nSyncope, seizures, transient paralysis, weakness,
\nparesthesias, black out spells
\nHeme\/Lymph\/Endo
\nHIV status, bruising, blood transfusion hx, night
\nsweats, swollen glands, increase thirst, increase
\nhunger, cold or heat intolerance
\nPsychiatric
\nDepression, anxiety, sleeping difficulties, suicidal
\nideation\/attempts, previous dx
\nOBJECTIVE
\nWeight BMI Temp BP
\nHeight Pulse Resp
\nGeneral Appearance
\nHealthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
\nSlightly somber affect at first, then brighter later.
\nSkin
\nSkin is brown, warm, dry, clean and intact. No rashes or lesions noted.
\nHEENT
\nHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
\nintact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
\nlight reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
\nNeck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
\nOral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
\nCardiovascular
\nS1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
\nPulses 3+ throughout. No edema.
\nRespiratory
\nSymmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
\nGastrointestinal
\nAbdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
\nBreast
\nBreast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
\nGenitourinary
\nBladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
\ndistribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
\nA small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
\nand nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
\nUterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
\nNo adnexal masses or tenderness. Ovaries are non-palpable.
\n(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
\n(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses\u2014Males: prostrate is
\nsmooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
\nMusculoskeletal
\nFull ROM seen in all 4 extremities as patient moved about the exam room.
\nNeurological
\nSpeech clear. Good tone. Posture erect. Balance stable; gait normal.
\nPsychiatric
\nAlert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
\nclear and of normal rate and cadence; answers questions appropriately.
\nLab Tests
\nUrinalysis \u2013 pending
\nUrine culture \u2013 pending
\nWet prep – pending
\nSpecial Tests
\nDiagnosis
\nDifferential Diagnoses
\no 1-
\no 2-
\no 3-
\nDiagnosis
\no
\nPlan\/Therapeutics
\no Plan:
\n\u25aa Further testing
\n\u25aa Medication
\n\u25aa Education
\n\u25aa Non-medication treatments
\nEvaluation of patient encounter<\/p>\n","protected":false},"excerpt":{"rendered":"
SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care \u201cin quotes\u201d HPI: Describe the course of the patient\u2019s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2474,2482,2483],"tags":[2368,2479,2477,2485,2476,1481,2475,2484,2478],"class_list":["post-6941","post","type-post","status-publish","format-standard","hentry","category-psyc-essays","category-psyc-paper-writing-service","category-psychology-dissertation-writing-service","tag-masters-essays","tag-psyc","tag-psychology-assignment","tag-psychology-case-study","tag-psychology-dissertations","tag-psychology-essays","tag-psychology-research-papers","tag-psychology-thesis","tag-sociology-essays"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/6941","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=6941"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/6941\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=6941"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=6941"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=6941"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}