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SOAP Note Example 1

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SOAP Note Example 1
SOAP Note Example 1
SOAP Note Example #2:
Date/Time: MSIII Progress Note - Medicine (state which service)
S:
(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.
Slept poorly.
O:
(Objective):
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).
Gen:
A+O x 3 (alert and oriented to person, place, and time), flushed, moderate distress. MMM
(mucous membranes moist), fair skin turgor; WD/WN (well-developed/well-nourished)
HEENT:
(head, ears, eyes, nose, throat -- often combined into one description)
Head: NC/AT (normocephalic/atraumatic)
Eyes:
PERRLA (pupils equal, round, and reactive to light and accommodation), EOMI (extraocular muscles
intact).
Ears:
No erythema, no discharge, tympanic membrane intact.
Throat:
No erythema or exudates. Tongue protrudes straight.
Neck:
No nuchal rigidity, good ROM (range of motion); No masses/LAD (lymphadenopathy)
CV
: RRR (regular rate/rhythm) S1/S2, no S3 or S4, no m/g/r (murmurs, gallops, or rubs)
Pulm
: + R lower lobe dullness to percussion; increased tactile fremitis, increase BS (breath
sounds),
- bronchial BS, + whispered pectoriloquy; +fine crackles R lower third posteriorly.
- w/r/r
(wheezes, rubs, or rhonchi).
Abd
: Soft, NT (non-tender) ND (non-distended), +BS (bowel sounds), no rebound, guarding,
masses or HSM
(hepatosplenomegaly); Heme + (rectal exam positive for fecal occult blood)
Ext: no c/c/e (clubbing, cyanosis, edema), 2+ DP/PT (dorsalis pedis, posterior tibial)
Neuro:
CNI (cranial nerves intact)
Labs:
None
A:
(Assessment) 54 y/o white male PMH (past medical history) DK +Tob ppd x 20 years, with
one day h/o CAP
(community-acquired pneumonia).
P:
(Plan)
1. Pulm:
Pneumonia Continue 02 4L, Day I Ceftriaxone I g q12 Codeine prn for pleuritic
chest pain, Tylenol prn fever
2. Endocrine:
DM Type II Continue Glipizide qd c (with) daily accu-checks
3. FEN
: (fluids/electrolytes/nutrition) Full PO diet/liquids as tolerated. I/0's good, continue
D51/2 NS @ 80 cc/hr
4. Dispo:
Consult for Smoking Cessation Program
Jim Q. Student, MS III
(always sign notes), Pager #
SOAP Note Example 1