Episodic/Focused SOAP Note Template 2021

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Patient Information: NY 41yo Caucasian male S. CC: left sided flank pain. HPI: NY is a 41 year-old Caucasian male who had a sudden onset of left sided flank pain that started suddenly this mornin... g and has progressively gotten worse, patient states that the pain comes and goes and is sharp when the pain is present, patient states that the pain does not radiate Pt has not tried anything to relieve the pain, patient states pain is 2/10, but states the pain was 10/10 when it started. Current Medications: no current medications Allergies: Sulfa, patient gets a rash. Denies any environmental allergies PMHx: Immunizations up to date, last Td June 2010, No past surgeries, no past medical history Soc Hx: patient is married with no children, denies any tobacco use, denies any recreational drug use, occasional alcohol use. Patient is an electrician for Alliant Energy Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. GENERAL: No fever, chills, weakness or fatigue. RESPIRATORY: No shortness of breath or cough GASTROINTESTINAL: No nausea, vomiting or diarrhea. No abdominal pain. GENITOURINARY: No difficult urinating, no frequency, no urgency, no burning, no blood in the urine MUSCULOSKELETAL: left lower to mid back pain [Show More]

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