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SOAP Note Example #2:
Date/Time: MSIII Progress Note - Medicine (state which service)
(Subjective) Patients noted no n/v (nausea, vomiting), no d/c (diarrhea, constipation) this am. +fever
with shaking chills x 1 this am. Tolerated po
(oral intake) well. No complaints of dysuria or
abdominal pain. Last BM
(bowel movement) 2 days ago. Patient continues to cough,
productive of greenish-yellow sputum. No wheezing, hemoptysis, orthopnea or PND
(paroxysmal nocturnal dyspnea), +SOB (shortness of breath), + pain on R side with deep inspiration.
PE: (physical examination)
VS:(vital signs)T: 100.2, Tmax (maximum temperature) 102.6, BP 128/82 (115-130/72-84
(range)), RR: 20, HR: 98, regular, Pulse Ox 98% on 4L, I/O (in's and out's)=1.7/2.2 (liters).
A+O x 3 (alert and oriented to person, place, and time), flushed, moderate distress. MMM
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