Exam (elaborations)
NR 509 SOAP Note WEEK 1, NR 509 Advanced physical assessment. Chamberlain
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NR 509 SOAP Note WEEK 1, NR 509 Advanced physical assessment. Chamberlain
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SOAP NOTES TEMPLATES: Subjective
Information the patient or patient representative told you.
Initials: JT
Age: 28 years
Gender: Female
Height: 170cm
Weight: 90kg
BP: 142/82
HR: 86
Temp: 101.1
SPO2: 99%
Pain (1-10): 7
Allergies
Medication: Penicillin
Food: No known allergy
Environment: Cats
History of Present Illness (HPI)
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
Chief Complaint (CC): Acute pain of right foot
Onset: 7 days prior to exam
Location: Right foot, plantar aspect
Duration: 1 week
Characteristics: Throbbing, stabbing
Aggravating Factors: Bearing weight, ambulation
Relieving Factors: Rest, elevation, pain medication
Treatment: Tramadol
Current Medications
Medication Dosage Frequency Length of Reason for Use
Time Used
, SOAP NOTES TEMPLATE
Proventil inhaler Albuterol PRN Unknown Asthma
90mcg/spray
Tylenol 500mg PRN Unknown Headaches
Advil 600mg TID PRN Unknown Menstrual cramps
Tramadol 100mg TID 2 days Right foot pain
Advil 2 tablets TID Pain
Neosporin One application BID with Unknown Skin infection
dressing changes
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.
Ms. Jones has uncontrolled and unmonitored type II diabetes with an open right foot wound that she sustained one
week ago when she tripped on steps barefoot. She has asthma and was last hospitalized for asthma when she was in
high school. She has experienced an unexpected weight loss of ten pounds and has been excessively thirsty and
experiencing nocturia. Her menstrual periods are irregular and heavy, with her last menstrual cycle being three
weeks ago.
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
Ms. Jones is very active in church and with family, goes out occasionally with friends dancing, and enjoys bible
study and volunteering with her church. She previously lived alone but moved back in with her mom and younger
sister to help with finances after the death of her father. She is working on her bachelor’s degree in accounting. She
does not use tobacco products or illicit drugs but reports that she tried both when younger. Ms. Jones drinks diet
coke soda and drinks alcohol socially a couple times per month. She is currently single, not sexually active and not
taking contraceptives but used birth control while sexually active with previous partner. She has never been married
and has never been pregnant. She reports a total of three (guy) partners and denies any history of STI’s.
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.
Ms. Jones’ mom is fifty years old and has hyperlipidemia and hypertension. Her dad is deceased at fifty-eight years
in age from a motor vehicle accident that occurred last year but had a history of hypertension, hyperlipidemia, and
type II diabetes. Her paternal grandmother has hypertension. Her paternal grandfather (Grandpa Jones) died in his
early sixties from colon cancer and had a history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died
at age seventy-three from a stroke and had a history of hypertension and hyperlipidemia. Her maternal grandfather
(Poppa) died at age seventy-eight from a heart attack and had a history of hypertension and hyperlipidemia. Ms.
Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports
that he is overweight as well as most of her family. Her paternal uncle is an alcoholic.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
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