SOAP Note tasks
1. Give the main headings of the below parts of a SOAP Note: subjective, objective, assessment
or plan.
Continue low molecular weight heparin for DVT prophylaxis. _____________________
Abdomen- mild distension, minimal diffuse tenderness, bowel sounds are active. ___________________
Small bowel obstruction with resection and lysis of adhesions. Post-op day #1. ___________________
Some discomfort with movement. ______________________
No flatulence or bowel movement since surgery. _____________________
Will continue to monitor patient. ______________________
CV- RRR, no murmurs or gallops. ____________________________
2. Give the subheadings of the below parts of a SOAP Note - Patient Note: CC, HPI, ROS, PMH,
DHx, FHx or SHx.
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
Patient was shoveling snow when pain started in the low back on the right side.
HTN – Controlled with Metoprolol. No past surgeries
Metoprolol for HTN. Allergies: NKDA
Activity makes pain worse, nothing makes it better.
Smoked 15 years ago, unknown pack years. 3 glasses of wine/week. Bank Teller.
Denies change in weight, fatigue, insomnia
Mother arrhythmia and CAD, Father CAD.
Denies recent fractures, sprains, strains, limited use of any joint
35 yo Caucasian male presents with low back pain x 2 days.
Pain started at an 8/10 and now is a 6/10 pain described as tight and constant.
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)