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Medical Assistant NetSOAP 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.
SOAP Note Examples
Soap Note Example 1:
Patient Name: Robert Kryle DOB: 12/31/1961
Record No. K-6112r809
Date: 09/09/99
SPt. 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.
OWT = 210 lbs HT = 60 BW = 115 lbs Chol = 255 BP = 120/75
AObese at 183% IBW, hypercholesterolemia
PLong 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
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Soap Note Example 2:
Patient Name: Lisa Brown DOB: 2/3/1960
Record No. B-583uw809
Date: 10/19/99
SPt. here for weekly BP check, no complaints. NKDA, NKA.
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue 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
SPt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue 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
SPain in left hip x 3 months; worse when walking or doing exercise. NKDA.
OWt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness.
APossible osteoarthritis; R/O rheumatoid arthritis
Pbloodworksed 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
SMild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening at tip of penis, NKA.
ODischarge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is positive.
ANon-Gonorrheal Urethritis
PDoxycycline 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
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