SOAP Note
Name (Initials): W.K. Date: 11/2/2018 Time: 0930
Age: 18 Sex: M
SUBJECTIVE Data
Chief Complaint (CC):
Reason given by the patient for seeking medical care “in quotes”
“I have been having clear discharge f
...
SOAP Note
Name (Initials): W.K. Date: 11/2/2018 Time: 0930
Age: 18 Sex: M
SUBJECTIVE Data
Chief Complaint (CC):
Reason given by the patient for seeking medical care “in quotes”
“I have been having clear discharge for the last week. It burns when I pee and sometimes even when I’m
not.”
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/severity, timing,
remitting/exacerbating, factors, associated manifestations.
Patient’s symptoms began about a week ago. Clear discharge out of urethral meatus and burning when
urinating. Patient also states it burns sometimes even when he isn’t urinating. More of a burning sensation
rather than pain. Patient had unprotected sex about three weeks ago.
Medications: (Name of the medication, route, dosage, and reason for med)
Medication Intolerances: None
Past Medical History (PMH)
Allergies (Drugs, Food, and Environmental): NKDA
Tobacco, alcohol, or illicit drug use in the past: Tobacco and alcohol
Chronic Illnesses/Major traumas: Appendicitis
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