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Encounter date: ________________________
SOAP Adult
Patient Initials: __________ Gender: Male____ Female___
Transgender ____ Age: _____
Race: __________________
Chief Complaint:
_____________________________________________________
___________
HPI:_________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__
Allergies
(Drug/Food/Environmental/Herbal):_______________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
______________________
Current perception of Health: Excellent Good Fair Poor
PMH:
_____________________________________________________
___________________
PSH:
_____________________________________________________
___________________
Hospitalizations:
_____________________________________________________
_________
Current Meds:
_____________________________________________________
_________
Family
History:______________________________________________
_________________
Social history: __Married __Widowed __Single __ Divorced
__Cohabitating Partner
Lives: __Home __Alone __ Family __Caretaker __ACLF __
SNF ___Other:
Smoke: ______________ETOH: ________________
Recreational Drug Use: _____________
Immunization HX: Please Document Date of Immunization or
Date of Disease.
Immunizations
Pneumovac
HPV
HEP B
MMR
Varicella
TD/Tdap
FLU
Other:
DATE:_____
DATE:___
1.
1.
1.
2.
2.
2.
3.
Disease
Review of Systems:
General______________________________________________
_________________________
HEENT______________________________________________
_________________________
Neck________________________________________________
________________________
Lungs
_____________________________________________________
___________________
Cardiovascular
_____________________________________________________
___________
Breast
_____________________________________________________
___________________
GI
_____________________________________________________
______________________
Male/female genital
_____________________________________________________
________
GU
_____________________________________________________
_____________________
Neuro________________________________________________
_________________________
Musculoskeletal_______________________________________
_________________________
Activity & Exercise
_____________________________________________________
________
Psychosocial
_____________________________________________________
______________
Derm________________________________________________
_________________________
Nutrition
_____________________________________________________
_________________
Sleep/Rest
_____________________________________________________
_______________
LMP_____________ Physical Exam
BP__________TPR_______ ________Ht. ________ Wt.
_________________ Wt. Change____ BMI_____________ O2
SAT%__________________
General______________________________________________
_________________________
HEENT______________________________________________
_________________________
Neck________________________________________________
_________________________
Pulmonary____________________________________________
_________________________
Cardiovascular________________________________________
_________________________
Breast_______________________________________________
_________________________
Abdomen_____________________________________________
_________________________
Rectal_______________________________________________
_________________________
Male/female
genital_______________________________________________
______________
Musculoskeletal_______________________________________
_________________________
Neuro________________________________________________
_________________________
Derm________________________________________________
_________________________
Psych________________________________________________
_________________________
Misc.________________________________________________
_________________________
Assessment:
Significant Data/Contributing Dx/Labs/MiscDifferential
Diagnoses
1.
2.
3.
Diagnoses
1.
2.
3.
Plan
Diagnosis # 1
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Diagnosis # 2
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Diagnosis # 3
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Signature_____________________________________________
________________________
Cite current evidenced based guideline(s) used to guide
careMandatory)
1.___________________________________________________
__________________
DEA#: 101010101 Barry University
LIC# 1010101010101
College of Nursing Clinic
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age _______________
Address: ________________________________________
Allergies: _____________________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature:
_____________________________________________________
_______

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Encounter date ________________________SOA