SOAP Note
Name (Initials): R. P. Date: 11/7/2018 Time: 1000
Age: 38 Sex: F
SUBJECTIVE Data
Chief Complaint (CC):
Reason given by the patient for seeking medical care “in quotes”
“I am here today because I think I h
...
SOAP Note
Name (Initials): R. P. Date: 11/7/2018 Time: 1000
Age: 38 Sex: F
SUBJECTIVE Data
Chief Complaint (CC):
Reason given by the patient for seeking medical care “in quotes”
“I am here today because I think I have a yeast infection. I am having discharge and itching.”
History of Present Illness (HPI):
Describe the course of the patient’s illness, including when it began, character of symptoms, location where
the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related
diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Include the 7 attributes of the symptoms: Location, quality, quantity/sverity, timing, remitting/exacerbating,
factors, associated manifestations.
Began about 1 week ago. No pain just itching very bad with discharge. “It has begun to burn when I
urinate from the itching. Scratching makes it worse and I have tried not to but cant help it. Nothing makes
it feel better. I tried using monostat cream but it didn’t help.”
Medications: (Name of the medication, route, dosage, and reason for med )
Orthotricycline PO for birth control daily.
Medication Intolerances: N/A
Past Medical History (PMH)
Allergies (Drugs, Food, and Environmental): N/A
Tobacco, alcohol, or illicit drug use in the past: Drinks an occasional glass of wine socially with
friends. Denies smoking or substance abuse.
Chronic Illnesses/Major traumas: N/A
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