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SOAP Note Template
Initials: T.J. Age: 28 Gender: Female
Heigh t
Weigh t
BP HR RR Temp SPO2 Pain Allergi es 170 cm
89kg 140/ 81
F
97% Medication: Penicillin - Rash Food: KNA Environment: Dust – asthma exacerbation, runny nose, watery eyes Cats – sneezing, itchy and watery eyes, runny nose chest tightness, wheezing History of Present Illness (HPI) Chief Complaint (CC)
“breathing problems” CC is a BRIEF statement
identifying why the patient
is here - in the patient’s own
words - for instance
"headache", NOT "bad
headache for 3 days”.
Sometimes a patient has
more than one complaint.
For example: If the patient
Onset 2 days ago
Location Chest
Duration 5 minutes at the longest every 4 hours: 5 times a day
Characteristics Wheezing, Chest tightness, difficulty breathing, cough
Aggravating
Factors
Cat’s, dust, laying down at night, or increased physical activity
Relieving Factors Drinking water helps cough, albuterol helps within 5
minutes
S: Subjective Information the patient or patient representative told you
Treatment Albuterol inhaler, 3 puffs every 4 hours presents with cough and
sore throat, identify which
is the CC and which may be
an associated symptom
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or
homeopathic products.
Medication
(Rx, OTC, or
Homeopathic)
Dosag e
Frequency Length Time^ of Used
Reason for Use
Albuterol (Proventil) inhaler
90 mcg each puff 2 - 3 puffs Every four hours
Chest tightness, or wheezing due to asthma Tylenol Gel caps, extra strength
500 mg 1 capsule (^) Once a week or less
Headache
Advil 200 mg tablets 3 - 200mg tablets (^) First two
days of menstrual cycle
For menstrual cramping
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Never been married, denies pregnancies. Employed since high school and is a supervisor.
Hobbies include reading, attends church, streams TV and documentaries. Denies physical activity outside of work, walks frequently during work hours.
Not currently sexually active. Sexual activity began at the age of 18. Straight sexual orientation. Used condoms and the pill for birth control. Lives with mother and sister who are supportive. Has smoke detectors that are working.
Uses seat belts. Social alcohol use, 0 - 4 alcoholic drinks on the weekends. Denies tobacco use, current or past. Is occasionally exposed to second hand smoke through friends.
Denies current illicit or recreational drug use. Hx of marijuana use in the past, denies current use, last used at the age of 21. Stopped use due to asthma exacerbation.
In college obtain bachelor’s in accounting – 2 semesters left Sleeps about 6 - 7 hours a night.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition,
contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included.
Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Father - HTN, T2DM, Hyperlipidemia – deceased due to car accident 6 months ago Mother – HTN, hyperlipidemia - living
Sister – Asthma – living Brother – Obesity - living Paternal Grandfather- HTN, type 2 diabetes, hyperlipidemia, colon Cancer – deceased due to colon cancer.
☒Fatigue Feels tired due to lack of sleep
☐ Weakness Click or tap here to enter text.
☐ Fever/Chills Click or tap here to enter text.
☐ Weight Gain Click or tap here to enter text.
☐ Weight Loss Click or tap here to enter text.
☒Trouble Sleeping has been waking up 2 times per night with breathing problems
☐ Night Sweats Click or tap here to enter text. ☐ Other: Click or tap here to enter text.
☐ Itching Click or tap here to enter text. ☐ Rashes Click or tap here to enter text. ☐ Nail Changes Click or tap here to enter text. ☐ Skin Color Changes Click or tap here to enter text. ☐ Other: Click or tap here to enter text.
☐ Diplopia Click or tap here to enter text. ☐ Eye Pain Click or tap here to enter text. ☐ Eye redness Click or tap here to enter text. ☐ Vision changes Click or tap here to enter text. ☐ Photophobia Click or tap here to enter text. ☐ Eye discharge Click or tap here to enter text.
☐ Earache Click or tap here to enter text. ☐ Tinnitus Click or tap here to enter text. ☐ Epistaxis Click or tap here to enter text. ☐ Vertigo Click or tap here to enter text. ☐ Hearing Changes Click or tap here to enter text.
☐ Hoarseness Click or tap here to enter text. ☐ Oral Ulcers Click or tap here to enter text. ☐ Sore Throat Click or tap here to enter text. ☐ Congestion Click or tap here to enter text. ☐ Rhinorrhea Click or tap here to enter text. ☐ Other: Click or tap here to enter text.
Respirat ory
Neur o
Cardiovasc ular
☒Cough Non-productive, small
☐ Hemoptysis Click or tap here to enter text.
☒Dyspnea Shortness of breath with
☐ Syncope or Lightheadedness Click or tap here to enter text. ☐ Headache Click or tap here
☐ Chest pain Click or tap here to enter text. ☐ SOB Click or tap here to enter text. ☐ Exercise Intolerance Click or tap here
☐ Palpitations Click or tap here to enter text. ☐ Faintness Click or tap here to enter text.
☐ Pain Click or tap here to enter text.
☐ Stiffness Click or tap here to enter text.
☐ Crepitus Click or tap here to enter text.
☐ Swelling Click or tap here to enter text.
☐ Limited ROM
☐ Redness Click or tap here to enter text.
☐ Misalignment Click or tap here to enter text.
☐ Other: Click or tap here to enter text.
☐ Nausea/Vomiting Click or tap here to enter text. ☐ Dysphasia Click or tap here to enter text. ☐ Diarrhea Click or tap here to enter text. ☐ Appetite Change Click or tap here to enter text. ☐ Heartburn Click or tap here to enter text. ☐ Blood in Stool Click or tap here to enter text. ☐ Abdominal Pain Click or tap here to enter text. ☐ Excessive Flatus Click or tap here to enter text. ☐ Food Intolerance Click or tap here to enter text. ☐ Rectal Bleeding Click or tap here to enter text. ☐ Other:
☐ Urgency Click or tap here to enter text. ☐ Dysuria Click or tap here to enter text. ☐ Burning Click or tap here to enter text. ☐ Hematuria Click or tap here to enter text. ☐ Polyuria Click or tap here to enter text. ☐ Nocturia Click or tap here to enter text. ☐ Incontinence Click or tap here to enter text. ☐ Other: Click or tap here to enter text.
☐ Stress Click or tap here to enter text. ☐ Anxiety Click or tap here to enter text. ☐ Depression Click or tap here to enter text. ☐ Suicidal/Homicidal Ideation Click or tap here to enter text. ☐ Memory Deficits Click or tap here to enter text. ☐ Mood Changes Click or tap here to enter text. ☐ Trouble Concentrating Click or tap here to enter text. ☐ Other: Click or tap here to enter text.
O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
Click or tap here to enter text. GY N ☐ Rash Click or tap here to enter text. ☐ Discharge Click or tap here to enter text. ☐ Itching Click or tap here to enter text.
☐ Irregular Menses Click or tap here to enter text. ☐ Dysmenorrhea Click or tap here to enter text. ☐ Foul Odor Click or tap here to enter text.
☐ Amenorrhea Click or tap here to enter text. ☐ LMP: Click or tap here to enter text. ☐ Contraception Click or tap here to enter text. ☐ Other:Click or tap here to enter text.
Neuro Wheezing heard in posterior bilateral
lower lobes. Accessory muscle use
noted.
Spirometry results - FVC 3.91L, FEV
3.15L = 80% percent predicted ratio
Unable to Assess
No asymmetry noted in chest.
No deformities noted
in chest wall. No rales
or rhonchi noted.
No retractions noted.
No dull areas noted during percussion.
No absent breath sounds or
diminished areas. No
bronchophony noted
Unable to Assess
Cardiovascular
Unable to
Assess
Unable to
Assess
Musculoskel
etal^ Unable to
Assess
Unable to Assess
Gastrointest
inal^ Unable to
Assess
Unable to Assess
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C e B a C ch intervention. A CBC can help rule out infectious etiology (David & Esherick, 2019).
C “ h N e o s n t (^) e x- a ra t y this time” but do not leave any he A a c d h in e g st b x la - r n a k y_._ c N a o n i r n u te le rv o e u n t t o io t n he is r e s t e io lf l - o e g v i i e d s en o t f_._ c P o r u o g v h ide su a ch ra a ti s on p a n lee u a m n o d n e ia vi ( d D e o n m ce in - b o a e s t e a d l. i , n (^2) - t (^0) e (^1) x (^9) t ) c. itation for
Test Rationale/Citation
Diagnostics: List tests you will order this visit
Spirometry P: Plan
Performing a full spirometry exam will provide more information on the severity of the patient’s asthmaand level of obstruction. A spirometry test can also help rule out differential diagnosis of chronic Address all 5 parts of the comprehensive o tr b e s att r m uc e t n iv t e p p la u n lm_. I_ o f n yo a u ry^ ddd o is n e o a t s w e is (D h o to m o in r o d eee r t^ aan l., in^2 t^0 e^1 rv^9 e ). ntion for any part of the treatment plan, write
CMP (^) Kidney function test before steroid administration due to uncontrolled diabetes (David & Esherick,2019).
Medications: List medications/treatments including OTC drugs you will order and “continue previous meds”
if pertinent.
Dru g
Dosa ge
Length of Treatment Rationale/Citation
Prednisolone (^) 1mg/kg (50 mg) once a
day in the morning
7 days (^) For mild to moderate asthma exacerbations, 1mg/kg of an oral corticosteroid is standard per clinical guidelines (David & Esherick, 2019).
Beclomethasone dipropionate (QVAR)
80 mcg daily 4-6 weeks. (^) To help control her asthma, an inhaled corticosteroid should be added to her SABA to help control her symptoms in the future (Woo & Robinson, 2016). A stepwise approach should be used to taper medications as need, therefore a low dose should be start first (Woo & Robinson, 2016). If symptoms control is
Allergist
Pulmonolo
gist
Rationale/Citation
Referring a patient with allergy induced asthma to an allergist may help predict future exacerbations and help the patient identify other causes of asthma exacerbations (Domino et al., 2019). If the patient’s asthma symptoms do not improve, a
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referral to pulmonology may be warranted (Woo & Robinson, 2016). Education:
Asthma education
Asthma Action plan
education Reiterate
proper inhaler use
Spacer education
Strict ED warnings for worsening of symptoms
Rationale/Citation
Recent research has shown that the initiation of an asthma action plan for adults along with the reiteration of symptoms control and asthma education can decrease symptoms, hospitalization and even death related to asthma exacerbation ( Kouri, Kaplan, Boulet, & Gupta, S. (2019). Along with symptom control, quality of life is also increased due to an increased ability to perform normal activities (Kouri et al.,
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