SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC:  Reason given by the patient for seeking medical care “in quotes” HPI:  Use OLDCART acronym 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 ) write medicine the same way you write a Rx PMH (list approximate year of Dx of the disease or when surgical procedure performed) Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries Family History (list immediate family, age, disease, and whether is dead or alive) 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 (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory” General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”. Weight        BMI Temp BP Height Pulse Resp General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results) Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)  Diagnosis  Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out) · 1- · 2- · 3- Diagnosis with ICD 10 Code CPT Code/Office visit code: Plan/Therapeutics · Plan:  · Further testing · Medication · Education · Non-medication treatments · Follow Up · Referral · When to seek emergency care  Evaluation of patient encounter Document your level of interaction with the patient. Weaknesses: Strengths: Reflection: References: Week 2: Respiratory Clinical Case Patient Setting: 65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of b.

1. SOAP NOTE
Name:
Date:
Time:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in
quotes”
HPI: Use OLDCART acronym
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 ) write medicine the
same way you write a Rx
PMH (list approximate year of Dx of the disease or when
surgical procedure performed)
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
Family History (list immediate family, age, disease, and

2. whether is dead or alive)
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 (Start each sentence with words such as “Denies, admits,
complains, reports”, do not use the words “No, positive for,
negative for”. Do NOT list physical exam findings here. If the
body system not assess write “Non-Contributory”
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast

3. Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE- this is where you document physical exam
findings, do NOT use the word NORMAL to document a
finding, and instead explain what normal is. For example, the
gait is not normal, the gait is steady. If the body part not
assessed then type “Deferred”.
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological

4. Psychiatric
Lab Tests (lists any tests ordered and status of the test, if a
rapid test was done at the office, list the results)
Special Tests (List any imaging study or special test ordered
and status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you
considered, but then ruled out)
· 1-
· 2-
· 3-
Diagnosis with ICD 10 Code
CPT Code/Office visit code:
Plan/Therapeutics
· Plan:
· Further testing
· Medication
· Education
· Non-medication treatments
· Follow Up
· Referral
· When to seek emergency care
Evaluation of patient encounter
Document your level of interaction with the patient.
Weaknesses:
Strengths:
Reflection:

5. References:
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the
hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe
wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out
without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4
times per week average), serious MVA 10
weeks ago; post traumatic seizure 2 weeks after the accident;
anticonvulsant phenytoin started – no
seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild
congestive heart failure diagnosed 3 years ago;

6. placed on sodium restrictive diet and hydrochlorothiazide; last
year placed on enalapril due to
worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN;
Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of
coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies

7. NKDA
ROS
Positive for shortness of breath, coughing, wheezing and
exercise intolerance. Denies headache,
swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR
18
Gen: Pale, well developed female appearing anxious. HEENT:
PERRLA, oral cavity without lesions, TM
without signs of inflammation, no nystagmus noted. Cardio:
Regular rate and rhythm normal S1 and S2.
Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-
distended no masses. GU:
Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema,
on right, no bruising, normal pulses.
NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na - 134
K - 4.9

8. Cl - 100
BUN - 21
Cr - 1.2
Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%