SOAP Note Report Sample:
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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.