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SOAP Note Template

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☒Fatigue “ tired, because my cough keeps me up at night” ☐Weakness denies ☐Fever/Chills denies ☐Weight Gain denies ☐Weight Loss denies ☒Trouble Sleeping “cough has made it hard to fa... ll asleep” ☐Night Sweats denies ☐Other: Click or tap here to enter text. ☐Itching denies ☐Rashes denies ☐Nail Changes denies ☐Skin Color Changes d ☒Other: Has dry skin on legs. THINK 3 A’s Allergy,asthma,atopic dermatitis. ☐Diplopia denies ☐Eye Pain denies ☐Eye redness denies ☐Vision changes denies ☐Photophobia denies ☐Eye discharge denies ☒Earache Right ear pain started 1 day ago. ☐Tinnitus denies ☐Epistaxis denies ☐Vertigo denies ☐Hearing Changes denies ☐Hoarseness denies ☐Oral Ulcers denies ☒Sore Throat started 2 out of 10 pain, cobblestoning and erythema. ☐Congestion denies ☒Rhinorrhea reports always a little runny but the clear runny nose worse the last 5 days. ☒Other: Right ear canal erythema, tympanic membrane- pearly gray, intact, no bulge. Respiratory Neuro Cardiovascular ☒Cough reports productive cough, started 5days ago ☐Hemoptysis denies ☐Dyspnea denies ☐Wheezing denies ☐Pain on Inspiration denies ☐Sputum Production ☐Other: clear thin sputum ☐Syncope or Lightheadedness denies ☐Headache denies ☐Numbness denies ☐Tingling Click or tap denies here to enter text. ☐Sensation Changes ☐Speech Deficits denies ☐Other: Click or tap here to enter text. ☐Chest pain denies ☐SOB denies ☐Exercise Intolerance denies ☐Orthopnea denies ☐Edema denies ☐Murmurs denies ☐Palpitations denies ☐Faintness denies ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or tap here to enter text. MSK GI GU PSYCH ☐Pain denies ☐Stiffness denies ☐Crepitus unable to assess ☐Swelling denies ☐Nausea/Vomiting denies ☒Dysphasia states swallows okay but throat is sore. ☐Diarrhea denies ☐Urgency denies ☐Dysuria denies ☐Burning denies ☐Hematuria denies ☐Stress denies ☐Anxiety denies ☐Depression denies ☐Suicidal [Show More]

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