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Soap note Templet
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- NSG6435 soap note (NSG6435)
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- South University Online
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CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) NotesStudent Name: Course:
Patient Name: (Initials ONLY) Date: Time:
Ethnicity: Age: Sex:
SUBJECTIVE (must complete this section)
CC: Eye drainage
HPI: The patient is a 4-year-old with 3-day history of right eye drainage. The drainage has been yellowish white in
color and increasing in quantity every day. The parent reports that it seems to be itchy because the child is frequently
rubbing the eye. The parent denies left eye symptoms. The parent has tried using saline eye drops to clear the mucus
out but doesn't feel that this has helped much. The parent denies suspicion of a foreign body and no other known sic
contacts. The parent denies the child has had pain with movement of the eye and there has not been any erythema o
the skin surrounding the eye but does acknowledge the sclera has been red and eyelids slightly swollen in the mornin
when the child wakes up. The patient has not had a cough, runny nose, new rashes or fever. The patient has not had
similar symptoms in the past.
Medications:Tylenol as needed for pain or fever.
Saline eye drops to the right eye twice over the past 2 days.
Previous Medical History: Two episodes of otitis media last year, both treated successfully with cefdinir.
Developmental History:Meeting developmental milestones according to age. ASQ on record.
Allergies:Amoxicillin caused urticaria - May 2022
Medication Intolerances:Amoxicillin
Chronic Illnesses/Major traumas:Parent denies history of chronic health conditions or past trauma.
Immunizations:UTD for age
Hospitalizations/Surgeries:No prior hospitalizations or surgeries.
Health Promotion/Health Maintenance:Parent reports use of booster seat, wears helmet when riding bike. WCCs are
UTD.
Nutrition/Diet:Patient eats 3 meals per day with snacks in between. Picky eater. Drinks 2% milk.
Exercise/Regimen:Rides bike every day, hikes with parents.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: Parent denies having any substances in the house.
Safety Measures: No guns in the home, locks on medicine cabinets.
Screening exams:Tumbling E's performed, 20/30 right eye, 20/30 left eye, 20/20 both eyes.
FAMILY HISTORY (must complete this section)
M:No health issues.
MGM:Hypertension treated with thiazide.
MGF:Hypercholesterolemia.
F:Asthma
PGM:Asthma
PGF:Deceased. Cause of death was heart attack at 79 years of age.
Social History:Patient lives with parents in house. No pets. Attends preschool 4 days a week and plays soccer at the
recreation center on the weekends.
REVIEW OF SYSTEMS (must complete this section)
General:Parent denies abnormal weight loss/gain, no Cardiovascular: Patient denies any chest pain
fevers.
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