SOAP Note Report Sample:

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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.