SOAP Note Examples

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	SOAP Note Examples

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The four parts of a SOAP note are outlined below:

1. SUBJECTIVE —The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness and a multitude of other descriptions of dysfunction, discomfort or illness the patient describes.

2. OBJECTIVE —The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, feelt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

3. ASSESSMENT —Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

4. PLAN —The last part of the SOAP note is the plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions and follow-up directions for the patient.

The below SOAP note examples are as a medical assistant would enter them in a patient's record.

Abbreviations key:

WT = weight

HT = height

IBW = ideal body weight

BP = blood pressure

Chol = cholesterol

Pt = patient

RTO = Return to office

ROM = range of motion

R/O = rule out

PA= posterior/anterior

NKDA = no known drug

allergies.

NKA = No known allergies

P = pulse

Temp or T = temperature

BS = blood sugar

UA = urinalysis

VA = vision acuity

O.S. = left eye

O.D. = right eye

O.U. = both eyes

SOAP Note Examples

Soap Note Example 1:

Patient Name: Robert Kryle DOB: 12/31/1961

Record No. K-6112r809

Date: 09/09/99

S—Pt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next year and she would likt to begin working toward a weight loss goal that is realistic. NKDA, NKA.

O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75

A—Obese at 183% IBW, hypercholesterolemia

P—Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one week.

———————————————————————————

- Bob Ridman, CCMA

M. Myer, MD

Attention:

Soap Note Example 2:

Patient Name: Lisa Brown DOB: 2/3/1960

Record No. B-583uw809

Date: 10/19/99

S—Pt. here for weekly BP check, no complaints. NKDA, NKA.

O—BP 142/88; Atenolol 50 mg daily

A—hypertension controlled

P—Continue Atenolol; RTO 6 months

———————————————————————————

- Mary Thombs, CMA

Carlos Monila, MD

Soap Note Example 3:

Patient Name: Lisa Brown DOB: 2/3/1958

Record No. B-583uw809

Date: 04/21/00

S—Pt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex

O—BP 142/88; Atenolol 50 mg daily

A—hypertension controlled

P—Continue Atenolol; RTO 6 months

———————————————————————————

- Daisy Rodriguez, CCMA

Paula Klein, MD

Soap Note Example 4:

Patient Name: Robert Dreg DOB: 09/17/1967

Record No. D-679dk978

Date: 12/4/99

S—Pain in left hip x 3 months; worse when walking or doing exercise. NKDA.

O—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness.

A—Possible osteoarthritis; R/O rheumatoid arthritis

P—bloodwork—sed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2 months.

———————————————————————————

- Bob Ridman, CCMA

Brenda D. Fisgers, MD

Soap Note Example 5:

Patient Name: Paul Kessler DOB: 11/03/1961

Record No. K-470pk624

Date: 21/8/01

S—Mild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening at tip of penis, NKA.

O—Discharge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is positive.

A—Non-Gonorrheal Urethritis

P—Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for 10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices.

———————————————————————————

- Robert White, RMA

Ted Ricca, MD