SOAP Note Report Sample:

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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.