SOAP Note Report Sample:

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SOAP Note

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.