S.O.A.P. Note Template CASE ID #EENT DOCUMENTATION
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
C
hief C
o
m
plaint
What brought you here
...
S.O.A.P. Note Template CASE ID #EENT DOCUMENTATION
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
C
hief C
o
m
plaint
What brought you here
today…(eg. headache) “I think I have a sinus infection”
Histo
r
y
of P
r
ese
nt Illn
ess
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
Onset This is a 42 y/o Caucasian female who presents to the medical office
complaining of severe headache and pain in the past two weeks. She
suspects that it is a “sinus infection”. She further reported that she had
experienced sinus infection three times for the past 6 months. She reports
sinus pressure in addition to coughing at night, terrible congestion, and sore
throat. She further explains that she experiences pain above and below her
ears in addition to what feels like “pressure in the ears when she swallows”.
However, she denies any difficulties with breathing, having wheeze, and
chest pains. She also refutes night chills and sweats; hence, she does not
think she has fever. She reports having been taking Tylenol and Sufaded to
relieve headache but she does not think that they have helped her.
Location
Duration
Character
Aggravating/associate
d factors
Relieving factors
Temporal factors –
other things going on
Severity
P
ast
M
e
dic
al
Histo
r
y
Adult Illnesses,
childhood illnesses,
immunizations,
surgeries, allergies,
current medications
Adult illnesses: Sinus infections three times in the past 6 months.
Childhood illnesses/Immunizations: Not addressed.
Allergies: Allergic to Aspirin.
Surgeries: 5 years ago, had nasal polyps removed.
Current medication: Tylenol to relief headache.
F
a
mily
Histo
r
y
Include Parents,
siblings; grandparents
if applicable/known,
cause of death, age,
pertinent medical
Family history: Not addressed.
P
e
rso
n
al/S
o
cial
Histo
r
y
Education, marital
status, occupation,
alcohol/drug use,
smoking status, sexual
history if relevant,
exercise, nutrition,
religious preference if
known
No education, marital status, occupation, alcohol/drug use, smoking or
sexual status is assessed.
R
e
vie
w
of S
yste
ms
General: Positive for fatigue, negative for fever, chills or night sweat
Hair, Skin, & Nails: Not assessed in the interview
Head: Positive for severe headache and sinus pressure
Neck: Not assessed in the interview.
Eyes: Not assessed in the interview.
Ears: Positive for right ear pain and pressure
Nose: Positive for drainage and congestion, negative for loss of smell
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