SOAP Note Week Two United States University FNP592: Common Illnesses Across the Lifespan Dr. Theresa Gress October 1, 2020 SOAP Note Week Three ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian. S: CC: “Cough, runny nose, and sore throat x 7 days” HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian PMH: Allergies: No known drug allergies. Strawberries (rash), seasonal allergies Childhood: Asthma until high school, chickenpox at age 2 Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005) Medications: None Vaccinations: received childhood vaccines, Last flu shot given Oct 2019. Denies psychiatric history. Social History: Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink 2 months ago, Engaged, works in IT, Hobbies include archery. Family History: Mother died age 60-Diabetes II Sister 42yo living -HTN Maternal Grandma died age 67- Dementia ROS: General: No weight change, weakness, fatigue, fevers.. Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago. C/V: Denies chest pain, palpitations. Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting. Lymph: Denies swollen lymph nodes in neck. Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness. O: VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% - 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8 Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis. HEENT: Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Post.

1. SOAP Note Week Two
United States University
FNP592: Common Illnesses Across the Lifespan
Dr. Theresa Gress
October 1, 2020
SOAP Note Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male

2. presents to the clinic unaccompanied and appears to be a
reliable historian.
S:
CC: “Cough, runny nose, and sore throat x 7 days”
HPI: New Asian male patient 28 yo presents to the clinic
unaccompanied, complaining of non-productive cough, runny
nose and sore throat x 7 days (1/7/2020). Currently somewhat
controlling symptoms with Dayquil and Nyquil. Cough mild,
worsened when laying flat. Highest temp at home 99 degrees.
Patient wondering if he needs antibiotics. Rates pain in throat
as 4/10, described as “aching, swallowing makes it worse”,
relieved by Dayquil/nyquil. Denies headache, denies sick
contacts or recent travel. Denies feeling worse outdoors or
seasonally. He is a reliable historian
PMH:
Allergies: No known drug allergies. Strawberries (rash),
seasonal allergies
Childhood: Asthma until high school, chickenpox at age 2
Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)
Medications: None
Vaccinations: received childhood vaccines, Last flu shot given
Oct 2019.
Denies psychiatric history.
Social History:
Denies tobacco/e-cigarette use. Admits to occasional once every
2-3 months alcohol use – last drink
2 months ago, Engaged, works in IT, Hobbies include archery.
Family History:
Mother died age 60-Diabetes II

3. Sister 42yo living -HTN
Maternal Grandma died age 67- Dementia
ROS:
General: No weight change, weakness, fatigue, fevers..
Eyes: no vision change, corrective lenses, pain redness,
excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing change, tinnitus, earaches,
infection, discharge. POSITIVE FOR RHINORRHEA. No sinus
pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE
VOICE. No bleeding gums, dentures, sore tongue, dry mouth.
Last dental exam was 4 months ago.
C/V: Denies chest pain, palpitations.
Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH,
negative hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: No headache, dizziness, focal numbness/weakness,
nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergies or allergy to
pets, pollen or other. Denies frequent illness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% - 4/10 pain
in throat. Wt: 205 Ht: 72 in BMI: 27.8
Skin: Natural in color, warm, smooth and dry. Good skin turgor,
no lesions, rashes, ecchymosis or moles. Nails without clubbing
or cyanosis.
HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray
with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly
reddened bilat. Nares patent bilat. No sinus pain upon palpation.
Septum midline.
Throat: oral mucosa pink and moist, tongue mobile without
lesions, tonsils absent. Posterior pharynx with erythema but no
cobblestone appearance.
Neck: non-tender cervical area, no lymph nodes palpable. Non-

4. enlarged thyroid palpated. Trachea midline.
Neuro: Alert and oriented x 4.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good expansion.
Respirations are even and unlabored. No use of accessory
muscles, stridor, grunting, or nasal flaring. Lungs CTA
Bilaterally.
(***notice not all systems are in the PE when doing a focused
exam on a problem)
A:
Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS
1. Viral pharyngitis – most likely as evidenced by sore throat,
cough, no fever (Stead, 2019). (←←←←←that is a practice
treatment guideline)
2. Strep Throat – not as likely; no fever and 7 days duration,
age not as consistent with this dx
3. Allergic rhinitis – no report of sx increasing with outdoor
activity or exposure to allergens, sx with sore throat are less
likely for allergies.
DX: Viral pharyngitis
P:
In house throat swab for rapid strep - negative.
Continue to rest and drink lots of fluids (Cash & Glass, 2017;
Stead, 2019).
Continue OTC Dayquil/Nyquil PRN per directions on the box –
Safe dosing discussed, sedation may occur with Nyquil, avoid
driving or operating heavy machinery after taking.
Encourage tea with honey and lemon to help with cough and
sore throat.
Gargle with warm salt water 2-3 times a day for 30 sec, swish

5. and spit.
Do not drink alcohol while taking these medications.
Cover mouth when coughing, do not drink after other people
(Cash & Glass, 2017).
Return to office in 3-4 days if symptoms do not improve,
worsen, or get better and then again get worse (Cash & Glass,
2017).
Call 911 or go to ER for trouble breathing or any other
emergent concern (Stead, 2019).
References:
Cash, J. & Glass, C. (2017).
Family practice guidelines. New York, NY. Springer.
Stead, W. (2019). Symptomatic treatment of acute pharyngitis
in adults. In L. Kunnis
(Ed.).
UpToDate Retrieved February 12, 2020 from:
https://www.uptodate.com/contents/symptomatic-treatment-of-
acute-pharyngitis-
in-adults
Clinical Documentation Template

6. Directions:Students may use this general SOAP note template or
their own. Save a copy to your device to alter the document.
Use APA when called for by the rubric or assignment prompt.
The APA title page will be the first page, and the template will
start on the second page. End with your APA formatted
references. Keep in mind this template is structured for an
average, problem-focused visit. This template will not be
adequate for some special populations and situations
(newborns/pregnancy visits/child wellness, etc.). Students need
to use good clinical judgment and make additional headings and
sections when needed and remove others as applies.
Consider viewing the EMS documentation guidelines from the
US Department of Health and Human Services/CMS:
Documentation Guidelines - Reimbursement
Delete all text in red - these are instructions and not part of the
SOAP document.
Student Name and clinical course: (If no title page):
______________________
ID:
Client’s Initials*:_______Age_____
Race__________Gender____________Date of
Birth___________
Insurance _______________ Marital Status_____________
*It is recommended to include false initials and use Jan 1,
XXXX (correct year) to protect client confidentiality. Include
brief statement on whether the patient came to the clinic alone
or accompanied, and if so by whom, and whether they are a
reliable historian.

7. Subjective:
CC: Patient’s own words, a few words, a sentence or less.
Example: “cough and fever”
HPI:
In paragraph format, including at the minimum OLDCARTS.
Please start with demographics: AA, a 29 y.o. Asian female
presents to the clinic alone with complaint of _____________.
Onset, Location, Duration, Characteristics/context, Aggravating
factors or Associated symptoms, Relieving Factors, Treatment,
and Timing, Severity. Include any pertinent positives or
negatives.
Past Medical History:
· Medical problem list
· Preventative care: (if applicable to the case - Paps,
mammography, colonoscopy, dates of last visits, etc.)
· Surgeries:
· Hospitalizations:
· LMP, pregnancy status, menopause, etc. for women
Allergies:
Food, drug, environmental
Medications: include names, doses, frequency, and routes, and
reason in parenthesis if off-label or secondary use

8. Family History:
Social History:
-Sexual history and contraception/protection (as
applies to the case)
-Chemical history (tobacco/alcohol/drugs) (ask every
pt about tobacco use)
Other: -Other social history
as applicable to each case (diet/exercise, spirituality,
school/work, living arrangements, developmental history, birth
history, breastfeeding, ADLs, advanced directives, etc. Exercise
your critical thinking here - what is pertinent and necessary for
safe and holistic care)
ROS (write out by system):
Comprehensive (
>10) ROS systems for wellness exams or complex cases
only. Do not include all 14 systems for every SOAP unless
needed - review and document the
pertinent systems. Do not include diagnoses - those
belong in PMH. The below categories are per CMS guidelines.
Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:

9. Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Objective
Vital Signs: HR BP Temp RR SpO2
Pain
Height Weight BMI (be sure to include
percentiles for peds)
Labs, radiology or other pertinent studies: be sure to include the
date of labs - might be POC tests from today
Physical Exam (write out by system):
Start with a general survey:
Assessment
(you will often have more than one diagnosis/problem, but do
the differential on the main problem)
Differentials (with a brief rationale for each):
1.
2.
3.

10. Diagnosis (may have more than one, include ICD-10 if rubric or
as your instructor specifies)
Plan(4 pronged-plan for each problem on the problem list)
Diagnostics:
Treatment:
Education
Follow Up:
List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed
2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator,
ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when
sick

11. E. Return to clinic in 3-4 months to reassess
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