SOAP Note Template
Initials: tj Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain
Rating
Allergies (and reaction)
170 88 Click
or
tap
here
to
ente
r
text.
Clic
k or
tap
here
to
ente
r
text.
...
SOAP Note Template
Initials: tj Age: 28 Gender: female
Height Weight BP HR RR Temp SPO2 Pain
Rating
Allergies (and reaction)
170 88 Click
or
tap
here
to
ente
r
text.
Clic
k or
tap
here
to
ente
r
text.
Clic
k or
tap
her
e to
ent
er
text.
Click
or tap
here to
enter
text.
Click or
tap here
to enter
text.
Medication: penicillin-hives
Food: none
Environment: : Cat dander- sneezes, asthma flare-up, pruritus
History of Present Illness (HPI)
Chief Complaint (CC) Patient present to the clinic after having a “fender bender” approx 1 week ago,
now the patient is having headaches and neck pain.
CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset 5 days
Location Pain is located at the crown and back of head and c/o neck pain
Duration daily
Characteristics Dull, increased with movement
Aggravating Factors Non- radiating, dull and associated with neck pain
Relieving Factors Movement of head
Treatment Tylenol for headache
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Proventil 90 mcg, inhaler As needed 30 Asthma exacerbation- Rescue inhaler
for asthma exacerbation
Flovent Patient unaware of
exact dosage
daily 30 Asthma management
Tylenol 650mg as needed by As needed 30 For headaches
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