This example demonstrates a well-structured SOAP note from a Nurse Practitioner (NP) for a patient presenting with common symptoms. Remember, this is a sample and should not be used as a direct template for patient care. Always refer to your institution's guidelines and protocols.
Patient: Jane Doe, 45-year-old female
Date: October 26, 2023
Encounter: Follow-up appointment
S: Subjective
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Chief Complaint (CC): Persistent cough and fatigue for three weeks.
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History of Present Illness (HPI): Patient reports a persistent, non-productive cough for the past three weeks. The cough is worse at night and is accompanied by fatigue, mild muscle aches, and occasional headaches. She denies fever, chills, shortness of breath, or chest pain. She reports feeling generally tired and lacking energy. She denies any recent travel or exposure to sick individuals. She has tried over-the-counter cough suppressants with minimal relief.
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Past Medical History (PMH): Hypertension, well-controlled with Lisinopril 20mg daily. No known allergies.
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Medications: Lisinopril 20mg daily. Over-the-counter cough suppressant (brand name omitted for confidentiality).
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Allergies: NKDA (No Known Drug Allergies)
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Social History: Patient is a non-smoker, drinks alcohol occasionally (1-2 glasses of wine per week), and denies illicit drug use. She works as a teacher and reports moderate stress levels.
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Family History: Father with history of hypertension, mother with history of type 2 diabetes.
O: Objective
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Vital Signs: Blood pressure: 130/85 mmHg, Heart rate: 80 bpm, Respiratory rate: 16 breaths/min, Temperature: 98.6°F (oral), SpO2: 99% on room air.
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Physical Examination: General appearance: Appears well-nourished and in no acute distress. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen: Soft, non-tender, no hepatosplenomegaly. Neurological exam: Grossly intact.
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Laboratory Data: (If any tests were ordered, results would be included here, e.g., complete blood count (CBC), chest x-ray results).
A: Assessment
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Diagnosis: Acute bronchitis, likely viral in etiology.
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Differential Diagnoses: Considered other possibilities such as pneumonia, post-nasal drip, and other respiratory infections, but ruled out based on presentation and physical exam.
P: Plan
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Treatment: Continue monitoring symptoms. Encourage rest, hydration, and over-the-counter cough suppressants as needed. No antibiotics are indicated at this time given the likely viral etiology.
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Patient Education: Educated patient on the importance of rest, hydration, and symptom management. Instructed to return if symptoms worsen or new symptoms develop (e.g., fever, shortness of breath, worsening cough).
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Follow-up: Scheduled a follow-up appointment in one week to assess symptom improvement.
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Referral: No referral necessary at this time.
Frequently Asked Questions (PAA-style)
What is a SOAP note? A SOAP note is a method of charting patient encounters that uses a structured format: Subjective (patient's report), Objective (physical exam and test results), Assessment (diagnosis), and Plan (treatment and follow-up).
Why are SOAP notes important for NPs? SOAP notes provide a clear, concise record of patient encounters, facilitating communication among healthcare providers and ensuring continuity of care. They are also vital for legal and insurance purposes.
What should be included in the subjective section of a SOAP note? The subjective section includes information obtained directly from the patient, such as their chief complaint, history of present illness, past medical history, medications, allergies, social history, and family history.
How does the objective section differ from the subjective section? The objective section contains measurable and observable data, such as vital signs, physical exam findings, and laboratory results. It focuses on factual data, unlike the subjective section, which is based on the patient's report.
What is the purpose of the assessment and plan sections of a SOAP note? The assessment section includes the diagnosis or diagnoses. The plan section outlines the treatment plan, including medications, tests, procedures, patient education, and follow-up appointments.
This example showcases a comprehensive SOAP note. Remember that every patient encounter is unique, and the content of your SOAP notes will vary accordingly. Always prioritize accuracy, completeness, and clear communication.
