SOAP Note Template
Initials: E.P. Age: 78 years old Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
62
inches
54.43
kg
110/
70
92
... [Show More] 16 37.0 C 99% Medication: No known drug allergies
Food: No known food allergies
Environment: Reports latex allergy-contact dermatitis
History of Present Illness (HPI)
Chief Complaint (CC) “Pain in my belly” and “I’m having difficulty going to the bathroom” 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 Patient reports abdominal discomfort that started 5 days ago
Location Lower abdomen, PT states “low in my belly”
Duration Constant discomfort for 5 days and has gradually worsened over the last 2-3
days
Characteristics Constant “dull, crampy” abdominal pain that stays in one place. At onset of
pain patient reported 3 out of 10. Patient currently rates pain 6 out of 10.
Experiencing bloating and increased flatulence.
Aggravating Factors Moving around the house, gardening, eating
Relieving Factors Resting, and trying “not to move too much” which provides some relief but can
still tell the pain is present
Treatment Small sips of warm water without relief, no medications taken for symptoms
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
Accupril (Quinapril) 10 mg (1 tablet) One tablet by mouth daily
in the morning with or
without food
24 years For the treatment of hypertension
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S: Subjective
Information the patient or patient representative told you
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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.
Diagnosed with hypertension at the age of 54, compliant with diet and medications.
Immunizations up to date with the exception of the flu shot and pneumonia vaccine.
Surgical history includes gallstones and a cholecystectomy at the age of 42 and one caesarean section at the age of 40 with her last pregnancy.
Denies recent hospitilizations and broken bones.
No recent travel in multiple years.
Had one day of non-bloody diarrhea 3 days ago for 1 day with resolution of symptoms.
Last Pap smear 10 years ago.
Colonoscopy 10 years 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. Parks is a G3P3L2 retired nurse who worked in a rehab clinic for many years and is now a widowed Korean American who was born in San
Francisco and grew up in a small Korean community. Her spouse of 50 years died 6 years ago and she currently lives with her daughter Jennifer
who she has a great relationship with and is a 46 year old criminal defense attorney. Ms. Parks also has a son, Timothy, who is 48 years old and is
a director. She does not have any grandchildren. Her third pregnancy resulted in a stillbirth due to a cord accident at the age of 40.
Enjoys taking classes at the local community center to include water aerobics and pilates. She walks to the botanical gardens once a week but has
been unable to miss both of her exercise classes this week and unable to clean at home She stopped driving 5 years ago, but when she rides in a
car, which is usually with her daughter she wears her seatbelt consistently.
Reports having a gentleman friend who she last saw 1 ½ weeks ago and reports no vaginal intercourse and is having oral sex with him at this time.
Denies ever using tobacco and smokeless tobacco use. Denies ever using illicit drugs. Reports drinking one glass of dry white wine every Sunday
but has not had wine for 1 week. Avoids caffeinated drinks and soda and drinks 2 glasses of water per day. Reports eating low fat foods, healthy
proteins, Korean dishes for the holidays and eating very light in general. Drinks chamomile tea before bed once every two to three days. Last meal
was a little bit of toast this morning. Typical diet includes toast for breakfast or fruit, soup for lunch but occasionally skips lunch, and fish for dinner
with rice and alternates the fish with chicken. Avoids spicy, high fat foods such as junk foo [Show Less]