SOAP Note
Patient:
Age:
Sex:
SUBJECTIVE
CC & Agenda
HPI
• Location
• Intensity of Pain
o Scale of 0-10
o Constant?
o Does it get worse or better?
• Quality
• Onset/Timing
• Radiation
• AAA
o Alleviating
o Aggravating
o Associated Sx (open-ended then three specifics)
▪ Headache, blurred vision, fever, chills, N/V/D, SOB, chest pain
• IFI
o Ideas
o Fears
o Impact
Past Medical/Family/Social History
Medical:
• General state of health: excellent, very good, good, fair, poor
• PMHx
o Medical problems
o Psych history
• Depression screening
• Allergies
• Medications
• OBGYN
o Date of LMP
o Sexually active
o Number of sexual partners
o STIs/STDs
o Pregnancies & abortions
o Last pap & result
o Last mammogram & result
Surgical:
• Hospitalizations
• Surgeries
Screenings & Vaccines:
• Mammogram, Pap smear, Prostate screening, Colonoscopy/Stool test,
Cholesterol/T2DM/HTN screening, HepC screening
• HepB, Tdap, Flu shot, COVID, Pneumonia, Shingles
Family:
Social:
• Exercise, Diet
• Tobacco Use
• Alcohol Use
• Recreational drug use
• Education & Occupation
• Marriage & Home
o Who do you live with?
o What type of home?
o Pets, AC, Smoke & CO detectors
• Sexual activity
• Safety
• Support
o Seatbelt, sunscreen, passive smoke exposure
o Guns in home?
Review of Systems
All systems were reviewed and all pertinent positives and negatives were stated in the HPI.
Constitutional: No fever, No chills, No sweats, No weakness, No fatigue, No weight loss.
Eye: No redness or eye pain, No recent visual problem, No discharge.
Ear/Nose/Mouth/Throat: No decreased hearing, No ear pain, No ear discharge, No epistaxis, No
nasal congestion, No sinus pain, No sore throat, No tinnitus, No vertigo.
Respiratory: No shortness of breath, no cough, No sputum production, no wheezing, Denies
orthopnea, No pleuritic pain.
Cardiovascular: No calf pain, No chest pain, No palpitations, No claudication, No orthopnea, No
peripheral edema, No varicose veins.
Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, mild heartburn, No
abdominal pain, No hematemesis, No dysphagia, No jaundice, No melena.
Genitourinary: No dysuria, No hematuria, No frequent urinary tract infections, No urinary
incontinence, No urinary urgency, No vaginal discharge.
Hematology/Lymphatics: No anemia, No bruising tendency, No bleeding tendency, No swollen
lymph glands.
Endocrine: No excessive thirst, No polyuria, No cold intolerance, No heat intolerance, No
change in hair texture, No flushing.
Musculoskeletal: No back pain, No joint pain, No muscle pain, No muscle weakness, No
claudication, No gait disturbance, No joint swelling.
Integumentary: No rash, No pruritus, No dryness, No skin lesion.
Neurologic: No weakness, No altered mental status, No numbness, No dizziness, No memory
loss, No seizure, No syncope, No vertigo.
Psychiatric: No generalized anxiety, No depression, No memory difficulties, No sleeping
problems, No substance abuse.
OBJECTIVE
Vital Signs
BP:
T:
HR:
RR:
Wt:
Ht:
BMI:
Physical Examination
General Appearance
Patient is alert and oriented and does not appear to be in any acute distress.
Integumentary
Grossly intact, no rash, no lesions.
HEENT
Head: Normocephalic and atraumatic.
Eyes: Lids and conjunctivae are non-injected and no discharge. Extra-ocular movements intact,
pupils equal bilaterally.
Ears: No lesions on external ear. EACs clear and TMs clear, pearly gray.
Nose: No lesions on external nose, no sinus tenderness, no nasal discharge.
Mouth/Throat: No mouth or lip ulcers, no bleeding gums. No erythema or exudates on
oropharynx, mucous membranes are moist.
Neck: Neck is supple. No cervical or supraclavicular lymphadenopathy, no goiter, no palpable
thyroid mass noted.
Cardiovascular
Heart is of regular rate and rhythm, S1 and S2 audible, no murmurs, rubs or gallops.
Chest/Lungs
No absent or decreased breath sounds noted, no rhonchi, no wheeze, no rales. No hyperresonance
noted.
Abdominal Exam
Bowel sounds present, abdomen is soft, non-tender, non-distended. No organomegaly noted.
Extremities
Pulses present and equal in all extremities, no peripheral edema noted.
5/5 bilateral elbow flexion and extension, hand grip, finger abduction, thumb opposition
5/5 bilateral hip flexion, adduction, abduction and extension
5/5 bilateral knee extension and flexion
5/5 bilateral ankle dorsiflexion and plantar flexion
Neurological
CN II-XII grossly intact, sensation preserved throughout body, no gross deficits noted.
Appropriate balance, no gait ataxia noted.
Female Genital/Rectal Exam
Rectal Exam deferred at this time as not clinically indicated.
External Genitalia: No swelling, lesions, or rash noted.
Vagina: No lesions, no inflammation, no discharge noted.
Cervix: No lesions, no inflammation, no discharge, no tenderness.
Uterus & Ovaries: Uterus is palpable, freely movable, firm, non-tender. Ovarian adnexa were
palpable, freely movable.
Lab/Investigations
• CBC
• CMP with fasting glucose
• Lipid Panel
• Imaging Results
Assessment
Differential Diagnoses
Plan
Testing
Treatment
Patient Education
Follow Up
