SOAP Note Template
Initials: D.R. Age: 8 years old Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies
127
cm
40.9 kg 120/
76
100 28 37.2
... [Show More] C 96% Medication: No known drug allergies
Food: No known food allergies
Environment: No known environmental allergies
History of Present Illness (HPI)
Chief Complaint (CC) “I have been coughing a lot” 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 Started 5 days ago
Location Throat and right ear
Duration Throat pain x5 days and ear pain x1 day
Characteristics Productive cough every couple of minutes with clear sputum. Describes his
cough as “gurgly and watery” Cough keeps the patient up at night. Cough is
accompanied by a sore throat, right ear pain and worsening rhinorrhea with
clear discharge
Aggravating Factors Worsens at 2100 every night. Exposed to second hand smoke by his father
who smokes a cigar in the house multiple times a week.
Relieving Factors Temporary relief with “spoonful of purple cough medicine”
Treatment Patient’s mother has been giving the patient a “spoonful of purple cough
medicine” with temporary relief. The patient has tried resting and drinking
water without relief, the cough “stays the same”
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
Antitussive “One spoonful” by
mouth with or without
food
As needed for cough per
age/weight dosage on
manufacturer package
1 day Cough
Multivitamin One gummy by mouth
with or without food
Daily Unknown Supplement
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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 and treated with antibiotic therapy for pneumonia last year by an urgent care clinic. At the age of 2 the patient had “a lot” of recurrent
ear infections. Patient takes a daily gummy multivitamin but when his mom is not looking he “sneaks a few extra.”
Denies surgical history, broken bones, or recent hospitilizations. Denies ear surgery or ear tubes.
Immunizations up to date with the exception of the influenza vaccine. Immunizations: Hepatitis A:2 dose series completed at 15 months, Hepatitis
B: 3-dose series completed at 6 months, Pneumococcal: 4-dose series completed at 15 months, DTaP: 5-dose series completed at age 6, MMR: 2-
dose series completed at 6 years, Polio: 4-dose series completed at 6 years old.
The patient’s mother takes him to regular doctors appointments where he receives his vaccinations.
Had epistaxis once when the patient got hit on the nose by a ball during recess.
Patient was sick a couple of months ago with an upset stomach that resolved on it’s own “pretty fast.”
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.
Third grade student in Ms. Saint-Jean’s class who likes school but bores easily when the homework is too easy. Lives with his mom (who is a
stenographer), dad, Abuelo (maternal grandfather), Abuela (maternal grandmother) and no siblings. Primarily English speaking household with
some Spanish spoken intermittently. The patient likes to play video games, read, write stories, rides his skateboard and plays with his friend Tony.
The patient wears a helmet each time he rides his skateboard. There are no pets at home. The patients father smokes cigars in the home a couple
times a week. The mother asks the father to move outside with his cigar. Reports drinking plenty of water a day due to his Abuela (maternal
grandmother) making sure he drinks enough water. Uses seatbelts consistently and has working smoke detectors in his home. Patient missed 2
weeks of school last year when he was diagnosed with pneumonia.
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.
Mother-Type 2 diabetic, HTN, Hypercholesterolemia, spinal stenosis and obesity. Father-HTN, Hypercholesterolemia, childhood asthma and is a
cigar smoker in the house.
Maternal grandmother (living)-Type 2 diabetic, HTN. Maternal grandfather-Smoke [Show Less]