Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise. Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs - rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History: Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood. Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends. Review of Systems: General: + fatigue .

1. Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note
should include. Remember that nurse practitioners treat patients
in a holistic manner, and your SOAP Note should reflect that
premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old
Caucasian female who presents today with a productive cough x
3 weeks and fever for the last 3 days. She reported that the
“cold feels like it is descending into her chest.” The cough is
nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has
associated symptoms of dyspnea of exertion and fever. Her
Tmax was reported to be 102.4 last night. She has been taking
Ibuprofen 400mg about every 6 hours and the fever breaks, but
it returns after the medication wears off. She rated the severity
of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily

2. 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred
admission – RX’d with outpatient antibiotics and hand held
nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied
ETOH or illicit drug use.

3. Immunization History:
Her immunizations are up to date. She received the influenza
vaccine last November and the Pneumococcal vaccine at the
same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other
with prostate CA, dx at age 62. She has one daughter in her 30s,
healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city
in a moderate crime area with good public transportation. She is
a college graduate, owns her home, and receives a pension of
$50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. She has medical insurance but often asks for drug
samples for cost savings. She has a healthy diet and eating
pattern. There are resources and community groups in her area
at the senior center that she attends regularly. She enjoys bingo.
She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance
HEENT: No changes in vision or hearing; she does wear
glasses, and her last eye exam was 1 ½ years ago. She reported
no history of glaucoma, diplopia, floaters, excessive tearing, or
photophobia. She does have bilateral small cataracts that are
being followed by her ophthalmologist. She has had no recent
ear infections, tinnitus, or discharge from the ears. She reported
her sense of smell is intact. She has not had any episodes of
epistaxis. She does not have a history of nasal polyps or recent

4. sinus infection. She has a history of allergic rhinitis that is
seasonal. Her last dental exam was 3/2014. She denied
ulceration, lesions, gingivitis, gum bleeding, and has no dental
appliances. She has had no difficulty chewing or swallowing.
Neck: No pain, injury, or history of disc disease or
compression. Her last Bone Mineral density (BMD) test was
2013 and showed mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions,
masses, or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; she has history of COPD and community acquired
pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: No chest discomfort, palpitations, history of murmur; no
history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: No nausea or vomiting, reflux controlled. No abd pain, no
changes in bowel/bladder pattern. She uses fiber as a daily
laxative to prevent constipation.
GU: No change in her urinary pattern, dysuria, or incontinence.
She is heterosexual. She has had a total abd hysterectomy. No
history of STDs or HPV. She has not been sexually active since
the death of her husband.
MS: She has no arthralgia/myalgia, no arthritis, gout or
limitation in her range of motion by report. No history of
trauma or fractures.
Psych: No history of anxiety or depression. No sleep
disturbance, delusions, or mental health history. She denied
suicidal/homicidal history.
Neuro: No syncopal episodes or dizziness, no paresthesia,
headaches. No change in memory or thinking patterns; no
twitches or abnormal movements; no history of gait disturbance

5. or problems with coordination. No falls or seizure history.
Integument/Heme/Lymph: No rashes, itching, or bruising. She
uses lotion to prevent dry skin. She has no history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties, or history of transfusions.
Endocrine: No endocrine symptoms or hormone therapies.
Allergic/Immunologic: Has hx of allergic rhinitis, but no known
immune deficiencies. Her last HIV test was 10 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and
regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht:
5’2; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub, or gallop;
pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic
tenderness – diffuse – no rebound
Genital/Rectal: external genitalia intact, no cervical motion
tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development - some age-
related atrophy; muscle strengths 5/5 all groups
Neuro: CN II – XII grossly intact, DTR’s intact

6. Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes
ASSESSMENT:
Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Diagnostics:
Lab:
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Differential Diagnosis (DDx):
1.) Acute Bronchitis
2.) Pulmonary Embolis
3.) Lung Cancer
Diagnoses/Client Problems:
1.) COPD
2.) HTN, controlled

7. 3.) Tobacco abuse – 40-pack-a-year history
4.) Allergy to sulfa drugs – rash
5.) GERD – quiet, on no current medication
PLAN: [This section is not required for the assignments in this
course but will be required for future courses.]
© 2014 Laureate Education, Inc.
Page 4 of 4
© 2014 Laureate Education, Inc.
Page 3 of 4
Case Study—Jordan Cement Factories
It is widely evident that the period since the mid-1980s has been
marked by changes in the world economy that have led to
profound developments in the international operations,
strategies and structures of MNCs and many other organizations
worldwide. Among other things, such changes consisted of the
liberalization of financial markets, deregulation and
privatization of state enterprises, globalization and

8. intensification of international competition. In the face of these
changes MNCs have adopted fast track expansionary strategies,
such as cross-border mergers and acquisitions, and a variety of
non-equity arrangements such as management contracts and
licensing agreements. They have also increasingly expanded
their growth into developing countries of which many were
embarking on economic structural adjustment reforms and
privatization programmes under the directive of the World Bank
(WB) and International Monetary Fund (IMF), which led to the
sale of their state-owned enterprises, and in many cases, to
MNCs.
The Hashemite Kingdom of Jordan was one of the countries in
the Arab world in the Middle East region that had to undertake
structural adjustment programmes under the auspices of the WB
and the IMF and, as a result, a number of state enterprises were
privatized and sold to Western MNCs to improve their
efficiency and competitiveness. The first state enterprise that
was privatized was Jordan Cement Factories that was acquired
by a French MNC through the purchase of equity shares. Jordan
Cement Factories is a public shareholding company that was
incorporated in Jordan in 1951. The main activities of the
company are the manufacturing, production and trading of
cement and its by-products and until 2002 it had a monopoly
over the supply of cement in Jordan. The Jordanian government
and its institutions had long owned around 58 per cent of the
company's share capital. In November 1998, it sold 33 per cent
of these shares to Lafarge, a French MNC, that subsequently
increased its stake to 50.27 per cent controlling share.
The process of change
Jordan Cement became the subsidiary of Lafarge that had
strategic importance to the MNC because, according to the
General Manager of Jordan Cement, it was 'the first operation in
the Middle East and therefore could be the basis for market
access and further operations and developments in the area'. The
parent company has adopted a management style known as the
'Lafarge way'. Under this the organization seeks to encourage

9. personal initiatives and involvement of everyone in the
implementation of group strategy. At the same time, the MNC
was moving towards operating along global lines and as a result
was attaching great importance to the issue of integration. In
terms of HR, this is reflected in the implementation of
company-wide HR policies in respect of a number of issues.
Thus, in relations to this, the Middle East director for HR-
related issues noted that:
'We apply the same HR policies on everything - on all HR
related issues and on all other activities such as training and
development, etc. There are company-wide policies that will
apply as much as the local culture and the law allow us… we
apply the same policies because the parent company has its own
internal culture and we aim to achieve integration. This means
doing the same everywhere in the world. It is part of our
culture. Each function should have the same methods of doing
things, same understanding, and same efficiency.'
Accordingly, after the acquisition, the French MNC adopted a
gradual approach to change whereby it was envisaged that the
change process would occur over a period of between two and
three years. In this process, a 'methodological guide' is used to
integrate new subsidiaries, under which teams from different
functional areas are sent to the subsidiary to identify priority
actions that have to be undertaken within the first 100 days.
This action programme is, in turn, accompanied by the
development of a longer-term, two- to three-year, programme of
actions aimed at making the changes needed to integrate the
new subsidiary fully. The MNC adopted a gradual approach to
change due to three main considerations. First, there was a
desire only to introduce the changes after an appropriate
management infrastructure had been developed. Secondly, there
was a recognition that cultural change is a slow process, and
thirdly, there was a felt need to prepare employees adequately
for change.
In addition, the company used participative change processes
that encompassed the use of task groups and working parties,

10. and a bottom-up orientation to problem solving. Consequently,
and following the change project known as the JCF Horizon
2001 that was created and the HR audit that was conducted by
staff at the parent company, a range of new HR policies and
procedures were proposed. These policies included the
establishment of a new system for career management and
succession planning, the implementation of revised job
descriptions and a new job evaluation scheme, and the
development of improved policies in relation to performance
appraisal, recruitment and selection, and training and
development. This was in parallel with the implementation of a
new organizational structure under which a new HR division
was created. Under this new structure, the HR function gained
greater strategic importance, became part of the company's
overall strategic planning process and was directly linked with
the operating committee that was in charge of the daily
operations of the company, while previously the role of the
personnel function was mainly administrative, HR had no
representation at board level and its participation in planning
was very weak.
Furthermore, decision-making style, which was very centralized
before privatization, had to be changed after privatization.
Decentralization and delegation were seen as important changes
that needed to be introduced in order to create a management
style that was in line with the parent company's best practice.
Thus many positions were merged to reduce the number of
layers of management and senior managers were encouraged to
devolve greater authority to line managers. Line managers were
also given more HR responsibilities in such areas as
communication with employees; pay rises and promotion of
subordinates; the use of performance appraisal to determine the
level of bonus pay and the objectives of subordinates;
recruitment and selection; training of subordinates; planning
manpower requirements; communication with subordinates;
paying attention to the budget and control of costs; and the
dismissal and discipline of subordinates. Overall, line managers

11. participated in making such decisions contrary to the situation
in the period before the acquisition where decisions were made
centrally.
Changes were also introduced in a number of other areas such
as performance management, rewards, training and
development. Working parties were also created to carry out the
JCF Horizon 2001 project and the HR changes. These working
parties or task groups comprised staff from different functions
including members of the trade union. A key objective of the
new management was to involve the trade union in the changes
being made. Jordan Cement had a well-established and powerful
union and the company's employees were members of The
General Trade Union of Construction Workers. This
involvement of the trade union reflected the parent company's
participative culture. For example, the Middle East director for
HR-related issues observed that:
The parent company's culture is very humanistic and works with
the individuals. It is a consensus seeking culture rather than a
confrontation culture… and that employees are at the heart of
the organization… you cannot force change… change must
come indigenously. I mean people should be willing and should
be participating in change… otherwise, for example, you can
make the perfect organization on the table but you cannot
implement it because the unions are going to resist it and
because the individuals are going to resist. So you must have
ownership and participation to change and I think the parent
company is trying to do this and is trying to create participation
to change… you cannot change the culture overnight. You need
to convince the people that what you are bringing them is going
to serve them better.
It must be noted that the union gained power during the
privatization process due to the delicate political situation in
the country and its power continued to grow after the
privatization. The power of the union grew not only at the
company level but also at the national level and it obtained
further support from the public and the press, and from the

12. several actions it took that threatened the stability of the
company and the country. It also had international support as it
was a member of other international unions such as the Union of
Arab Workers. Thus, according to the union's president, during
the period when the company was considering a restructuring
based on the Jordanian Labour Law No. 31 article 33, which
gave the firm's owner the right to terminate the services of the
employees without compensating them, the union 'declared war
on the company' and announced strikes and sit-ins that were
widely supported in Jordanian society, and by national figures
and political parties. At the same time, for the government this
was a very sensitive situation since many of the company's
employees came from high unemployment and low income
regions and the company was considered to serve the national
interest by employing these people. As a result of the growing
influence of the union, it succeeded in obtaining several gains
such as the distribution of 4 per cent of the company's annual
profits to all company staff, pay increase on the basic salaries
of all employees, and among other things, it changed the terms
of the early retirement scheme and gained more favourable
terms and incentives for employees. The way that the MNC
dealt with the changes and the resistance if faced is illustrated
in the area of remuneration below.
Remuneration
Prior to privatization, pay was determined according to the
qualifications and experience of the individual and was made up
of a number of elements: basic salary, various allowances, a
production bonus and annual performance-based increases of
between £3.00 and £4.00. Shortly after privatization, it was
agreed to raise the basic salary by an average of £6.00 for every
employee. In addition, the existing production bonus was
doubled, and 4 per cent of the company's annual profits were
distributed equally to all the company's employees as a bonus.
These changes were made in response to forceful union claims
and against the background of an increase in union influence
stemming from the delicate political nature of the privatization

13. and a desire on the part of both the government and the
company to avoid any bad publicity during the early days of
privatization. In addition, a new company-wide performance-
related bonus scheme was proposed under which payments
would be distributed on the basis of individual performance.
Initially, the new bonus arrangements were only applied to the
cadre people because of union opposition to the revised bonus
arrangements. In the face of this opposition, the company
therefore later decided to link only half of the bonus to
individual performance. Accordingly, a decision was made to
distribute 2 per cent of annual net profit equally among the
1,800 non-cadre employees, while the other 2 per cent was to be
distributed according to their personal performance. In a similar
vein, the union was also able, against the background of its
enhanced negotiating power, to secure an increase from 75 per
cent to 86 per cent in the average annual appraisal mark, as the
following quote from the company's career manager illustrates:
'The main obstacle is the union. The annual appraisal is linked
to the annual increase and the bonus. Thus, the unions argued
that this affected the employees' incomes and demanded an
increase in the average mark from 75 per cent to 86 per cent. At
the end, the company had to make concessions and we reached
an agreement to have an average mark of 84 per cent'.
Comprehensive SOAP Template
This template is for a full history and physical. For this course
include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______

14. Note: The mnemonic below is included for your reference and
should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but
organize the information.
Chief Complaint (CC): In just a few words, explain why the
patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis
section of your note. Thorough documentation in this section is
essential for patient care, coding, and billing analysis. Paint a
picture of what is wrong with the patient. You need to start
EVERY HPI with age, race, and gender (e.g., 34-year-old AA
male). You must include the seven attributes ofeach principal
symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity

15. 4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal
supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods,
insects, and environmental factors. Identify if it is an allergy or
intolerance.
Past Medical History (PMH): Include illnesses (also childhood
illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and
types of operations.
Sexual/Reproductive History: If applicable, include obstetric
history, menstrual history, methods of contraception, sexual
function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug
use, patient’s interests, ADL’s and IADL’s if applicable, and
exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents,
grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and
support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that
covers the Chief Complaint, History of Present Illness, and
History (this includes the systems that address any previous
diagnoses).Remember that the information you include in this
section is based on what the patient tells you so ensure that you

16. include all essentials in your case (refer to Chapter 2 of the
Sullivan text).
General: Include any recent weight changes, weakness, fatigue,
or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:

17. Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, includewhat you see,
hear, and feel when doing your physical exam. You only need to
examine the systems that are pertinent to the CC, HPI, and
History unless you are doing a total H&P- only in this course.
Do not use “WNL” or “normal.” You must describe what you
see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity,
and gait. This may also include dress, grooming, hygiene, odors
of body or breath, facial expression, manner, level of
consciousness, and affect and reactions to people and things.
HEENT:
Neck:
Chest
Lungs:
Heart
Peripheral Vascular: Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:

18. Include any labs, x-rays, or other diagnostics that are needed to
develop the differential diagnoses.
ASSESSMENT: List your priority diagnosis (es). For each
priority diagnosis, list at least three differential diagnoses, each
of which must be supported with evidence and guidelines. For
holistic care, you need to include previous diagnoses and
indicate whether these are controlled or not controlled. These
should also be included in your treatment plan.
PLAN: This section is not required for the assignments in this
course (NURS 6512) but will be required for future courses.
Treatment Plan: If applicable, include both pharmacological and
non-pharmacological strategies, alternative therapies, follow-up
recommendations, referrals, consultations, and any additional
labs, x-ray, or other diagnostics. Support the treatment plan
with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety
recommendations, as well as any other health promotion
strategies for the patient/family. Support the health promotion
recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age,
include disease prevention recommendations and strategies such
as fasting lipid profile, mammography, colonoscopy,
immunizations, etc. Support the disease prevention
recommendations and strategies with evidence and guidelines.
REFLECTION:This section is not required for the assignments
in this course (NURS 6512) but will be required for future
courses. Reflect on your clinical experience, and consider the
following questions: What did you learn from this experience?
What would you do differently? Do you agree with your
preceptor based on the evidence?
© 2014 Laureate Education, Inc.

19. Page 1 of 4
1:
2:
3.
4.
5.