SOAP Note Template
Patient Data:
75 y.o. Caucasian female
Allergies: NKDA
Current Medications:
Subjective data:
Chief complaint: " "
HPI: Pt is a pleasant …
Medical History:
Surgical History:
Social History: denies smoking, denies alcohol, denies recreational drugs
Objective data:
Vital signs: BP , HR , T F, RR , O2
Physical exam:
GENERAL APPEARANCE: well-nourished, well-groomed in no acute distress.
HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light
and accommodation.
NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or
tenderness.
CHEST: Symmetric. Nontender to palpation.
LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
HEART: Regular rate and rhythm with normal S1 and S2. No murmur, click, rub or gallop.
ABDOMEN: Soft, obese, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or
hernia. Bowel sounds are present. No CVA tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema.
MUSCULOSKELETAL: Full ROM to all extremeties. Strength 5/5 throughout.
NEUROLOGIC: CN 2-12 intact. Sensation to touch and pain normal.
PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Mood
and affect are appropriate.
SKIN: Warm, dry, and well perfused. Good turgor.
Assessment:
1. ( )
2. ( )
3. ( )
Plan:
1. Medications: No additional medications at this time.
2. Procedures: No additional procedures at this time.
3. Physical medicine: No additional therapies at this time.
4. Imaging: No additional imaging at this time.
5. Psychological: No additional therapies at this time.
6. Referral: No additional referrals at this time.
7. Education:
Prescriptions:
Drug. Disp: # . Sig: . Refills: None
Quality Assurance:
99213
SOAP Example
Patient Data:
70 y.o. Caucasian male
Allergies: penicillin
Current Medications:
Metoprolol 50 mg PO daily
Aspirin 81 mg PO daily
Testosterone injection monthly
Metformin 500 mg PO daily
Glipizide 5 mg PO daily
Pantoprazole 20 mg PO Q AM
Diclofenac sodium 75 mg PO daily
Losartan potassium 25 mg PO daily
Amlodipine 5 mg PO daily
Subjective data:
Chief complaint: "BP check"
HPI: Pt is a pleasant 70 year old male here for a blood pressure check.
He has not been maintaining a blood pressure log at home. His blood pressures have been consistently
elevated in the clinic despite multiple medication management. The patient denies being followed by
cardiology or having an EKG in the last year. He denies headache, vision changes, chest pain or syncope.
The patient has been maintaining a blood sugar log at home with FSBS running between 85-125 both in
the am and pm. He reports taking his medications regularly. He denies symptoms of hyper- or
hypoglycemia at home. His last eye exam was 3 months ago.
The patient reports a history of stroke diagnosed by MRI at the VA about 3 years ago. He denies having
residual from any stroke. He denies weakness, numbness, dysphagia, aphasia or memory loss.
The patient complains of tingling in the fingers of both hands when performing certain activities like
reading or driving for long periods of time. He reports the tingling is in his fingers but not the thumbs,
denies pain, denies numbness. The patient reports that this tingling has moderate interference with his
daily activities. He denies using any home therapies to treat the tingling but reports it decreases with
resting his hands.
The patient reports receiving a pneumonia vaccine about 2 years ago and a flu vaccine this month.
The patient has smoked 1 PPD or slightly less for about 55 years. He declines assistance with smoking
cessation at this time.
Medical History: anxiety, hypertension, osteoarthritis, BPH, testicular hypofunction, diabetes mellitus II,
GERD, low back pain, depression, nicotine dependence, vitamin D deficiency, hypercholesterolemia
Surgical History: bilateral TKA 2010, ORIF right wrist s/p fracture 1983
Social History: smokes 1 PPD for 55 years, 3 alcoholic beverages weekly, denies recreational drugs
Objective data:
Vital signs: BP 177/90, HR 63, RR 18, T 97.9 F, O2 97%
Physical exam:
GENERAL APPEARANCE: well-nourished, well-groomed in no acute distress.
HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light
and accommodation, 3 mm.
NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or
tenderness.
CHEST: Symmetric. Nontender to palpation.
LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
HEART: Regular rate and rhythm with normal S1 and S2. No murmur, click, rub or gallop.
ABDOMEN: Soft, obese, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or
hernia. Bowel sounds are present. No CVA tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema. Swelling noted to bilateral wrists R>L.
MUSCULOSKELETAL: Full ROM to all extremeties. Strength 5/5 throughout.
NEUROLOGIC: CN 2-12 normal. Sensation to pain, touch, and proprioception normal.
PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact.
SKIN: Warm, dry, and well perfused. Good turgor.
Assessment:
1. (I10) Hypertension – Your blood pressures remain elevated despite taking your medications. Please
keep a log of am and pm blood pressures for the next month and bring to the next visit. You have been
educated on a heart healthy diet as well as the importance of increasing your exercise by walking at
least 30 minutes each day. You have verbalized understanding of this education. You have been
referred to cardiology for further evaluation and treatment. Please follow up with this provider as soon
as possible. EKG – HR 61, Sinus rhythm with first degree block
2. (E11.9) Type 2 diabetes mellitus – Continue checking you blood sugars daily and taking your
medications regularly. You have been educated on a healthy diet and exercise as noted above and
verbalized understanding.
3. (F17.290) Nicotine dependence – You have been educated on the risks of continued smoking
including stroke, cardiac event and death and verbalize understanding. You have also been educated on
community resources for smoking cessation and pharmaceutical aids available at the clinic. Despite this,
you continue to decline assistance with smoking cessation. Return to the clinic if at any point you are
willing to entertain smoking cessation as an option.
4. (R20.0) Tingling of skin – You have been prescribed braces for bilateral wrists to reduce the tingling
you have been experiencing. You should wear these for the majority of waking hours, especially when
performing activities that aggravate the tingling in your fingers.
5. (Z86.73) History of stroke – You have been educated on the correlation between smoking,
cholesterol. Blood sugar and hypertension and the risks for further strokes including debility and death.
You have been educated on appropriate diet and exercise for the prevention of further cerebrovascular
disease. Call 911 for any symptoms of stroke including facial or limb drift, changes in speech or changes
in mentation. You have verbalized understanding of this education.
6. (E78.1) Hyperglyceridemia – You have been educated on a healthy diet and exercise as noted above.
We have added CoQ10 to your medications, this has been sent to your pharmacy. Please continue to
take your medications as prescribed. This will be reevaluated with your next lab test.
Plan:
1. Medications: Add CoQ10.
2. Procedures: Lab work ordered including CBC, CMP, TSH, Vitamin B12, Vitamin D, lipids, HgA1c,
testosterone
3. Physical medicine: DME bilateral carpal tunnel wrist brace.
4. Imaging: No additional imaging at this time.
5. Psychological: No additional therapies at this time.
6. Referral: Referral sent to cardiology for uncontrolled hypertension.
7. Education: Educated on heart healthy diet and exercise. Stop smoking now. Follow up with
cardiology as ordered.
Prescriptions:
CoQ10 200 mg. Disp # 30. Sig: Take one tablet by mouth every morning. Refills: 2
Quality Assurance:
99214