SOAP Note Report Samples (4)

SOAP NOTE SAMPLE #1

RE: David Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

S: The patient presents for a physical. The back pain has been present for just a few days and is slightly worse with movement. He has had pains in his elbows for approximately four months. It is relatively constant, no extreme. It does tend to hurt when he supinates his forearm fully. He has also had some mild pain in the back. At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable. He has no other significant history. Social: He is a nonsmoker. Family history: His father does have some mild arthritis and also has hypertension and heart disease.

O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. Neck is supple without lymphadenopathy or bruits. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sound are active. He has some minimal tenderness in the right lower quadrant. Back: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position.

Laboratory studies were within normal limits, with the exception of his cholesterol which was 236 and his triglycerides which were 320. He is not watching his diet at all.

A: Strain of the lower back. I think this may well be due to his work as a clerk. He spends a lot of time at a computer keyboard.

P: He is to take the strain off of his elbows and lower back. I also gave him an instruction sheet on a low-cholesterol diet. He will try to follow this for six months, and we will recheck his cholesterol then. He asked if I would recommend taking niacin. I told him that it might have some beneficial effect and was probably relatively safe for him to take.




SOAP NOTE SAMPLE #2

RE: David Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

S: Patient states that she has always been overweight. She is very frustrated with trying diet. Her 20 year class reunion is next year and she would like to begin working toward a weight loss goal that is realistic.

O: Wight: 210 lbs. Height: 60”. Cholesterol: 225. Blood Pressure: 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: Patient is to begin a 1500 Calorie diet with walking 20 minutes per day. I instructed patient on lower fat food choices and smaller food portions. Patient will keep a daily food and mood record to review next session. She is to follow up in one week.




SOAP NOTE SAMPLE #3

RE: David Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

S: Patient has pain in the left hip for 3 months. It is worse when walking or doing exercise. She has no known drug allergies.

O: Wight: 195 lbs. Height: 5’52”. She has normal ROM of both hips. There is no swelling or redness.

A:She has possible osteoarthritis; rheumatoid arthritis.

P:Update blood work to include sed rate and rheumatoid factor. Get an x-ray of the left hip. Take ibuprofen 600 mg p.o. t.i.d. Patient will follow up in 2 months.




SOAP NOTE SAMPLE #4

RE: Debra Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

S: Patient reported difficulties in home care, in particular cleaning and shopping. She expressed concern of putting strain on her son who is her primary caregiver. She is keen to get back to previous roles within home (mother/housewife) and visit friends.

O: Patient was polite and joking throughout the exam. She required assistant with getting on and off the exam table. She is unsteady on her feet. She has reduced mobility and endurance.

A:The patient is at risk of further falls. She would benefit from home visit to investigate risks in home environment.

P:I am going to refer her for physical therapy. We discussed the use of a cane to help with ambulation. She will follow up with me again in two months.