SOAP NOTE

Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC:

Reason given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s 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 past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart

disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, marijuana. Safety status

ROS
General

Weight change, fatigue, fever, chills, night sweats,

energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin

discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, TB

Eyes

Corrective lenses, blurring, visual changes of any

kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, black tarry

stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of

urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual

complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or

discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture

hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness,

paresthesias, black out spells
Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night

sweats, swollen glands, increase thirst, increase

hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal

ideation/attempts, previous dx

OBJECTIVE

Weight BMI Temp BP
Height Pulse Resp
General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Slightly somber affect at first, then brighter later.
Skin

Skin is brown, warm, dry, clean and intact. No rashes




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