SOAP Note Template
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain
Ratingwh
0/10
Allergies (and reaction)
170
cm
89 kg 140/
81
89 20 98.5 97 Medication: Penicillin – rash/hives
Food:
...
SOAP Note Template
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain
Ratingwh
0/10
Allergies (and reaction)
170
cm
89 kg 140/
81
89 20 98.5 97 Medication: Penicillin – rash/hives
Food: n/a
Environment: Cats – Sneezing, itching, asthma attacks, rhinorrhea
History of Present Illness (HPI)
Chief Complaint (CC) breathing problems, chest tightness, and wheezing 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 2 days ago
Location Chest
Duration Q 4 hours
Characteristics Chest tightness, wheezes, shortness of breath,
Aggravating Factors Cats
Relieving Factors Inhaler
Treatment Proventil Inhaler
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 Inhaler 90 mcgs BID – TID PRN 25 ½ years Asthma
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