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Sample Soap

Sample Soap

Ratings: (0)|Views: 18,776|Likes:
Published by Douglas Greg Cook
This is an example of a physician/nurse practitioner SOAP note. The take home from this is they way the different body systems are organized...you can organize your narrative notes by systems. Note that the Review of Systems is all subjective info, while all the objective findings that are found on exam are included under the "objective" section. Hope this helps.
This is an example of a physician/nurse practitioner SOAP note. The take home from this is they way the different body systems are organized...you can organize your narrative notes by systems. Note that the Review of Systems is all subjective info, while all the objective findings that are found on exam are included under the "objective" section. Hope this helps.

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Categories:Types, School Work
Published by: Douglas Greg Cook on Jul 10, 2011
Copyright:Attribution Non-commercial


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Student: Greg CookDate of patient visit: 3/11/2011Reason for Patient Visit: Annual physical
Identification and problem statement:
Patient initials: J. H.Age: 50Sex: MaleMarital Status: MarriedRace: CaucasianOccupation: Police dispatcherSource of Information: Patient; appears reliableProblem Statement: “I’m here for a physical. It’s been about a yearsince I’ve seen a doctor. My wife and I are applying for foster parentstatus and are required to have a physical”.
50 y/o white male presents today for annual physical. Patientstates requires physical for foster parent status approval. Patientstates that he is usual state of “good health”. Reports that he hasoccasional “problems with hemorrhoids” (occasional notice of brightred streaks on stool and toilet paper after passage of large hardstools). States that his hemorrhoids are not currently causing him anyproblems. He also reports occasional and self-limiting episodes of diarrhea, which he attributes to stress (currently symptom free).Denies chest/abdominal pain. States usually has one formed stool inmorning. Denies change in bowel frequency or consistency (except aspreviously noted). Denies nausea/emesis. Denies dark tarry stools.Denies recent weight gain/loss. Eats regular diet with no recentchanges. His only other complaints are for seasonal itchy eyes,sneezing, and runny nose (currently symptom free).
Pertinent Medical
Denies chronic medical conditions.Immunizations up to date (last TD 2006). States passed 5mm kidneystone 2007. Right ankle fracture (non-displaced, football) 1991.Preventive screenings: colonoscopy (never). Patient does not wantcolonoscopy because he does not like the, “idea of anesthesia”. Lasteye exam 2010, last dental exam 2009. 
Current Medications
NKDA. Ibuprofen, 600mg PO prn knee pain.
Surgical History
Vasectomy 2007.
Family History
Father died at 74 years of age from “prostate cancerthat traveled to brain”. Mother living (85 years old) has history of “glaucoma and osteoarthritis”. Has one sibling (brother, 57 years old)with history of “hypertension, otherwise in good health”.
Social History
 The patient reports his health to be “pretty good”. Henever smoked and admits to drinking 1 six-pack of beer every monthor so. The patient is married and has no children. He is physicallyactive outside of work (plays intramural baseball and takes care of histhree horses), but does not participate in routine aerobic exercise. Heconsciously watches his caloric and fat intake, but is otherwise on aregular diet. He is sexually active in a monogamous relationship. Hedenies the use of recreational drugs. His wife also works outside of thehome and they are both self-supportive on their current combinedincomes. He has no current concerns regarding his activities of dailyliving.
Review of SystemsGeneral
Reports in usual state of “Good” health and weight. Deniesfever, chills, recent weight gain or loss, weakness, fatigue, pain. Statesthat his last physical exam was in 2010.
Denies recent rashes or changes in texture or moles.
Denies headaches. Denies problems with vision or hearing.Wears reading glasses, last eye exam 2010. Denies use of hearingaids. Denies glaucoma or cataracts. Denies frequent nasalcongestion/stuffiness, but occasional seasonal teary eyes, runny noseand sneezing (currently asymptomatic). Denies nosebleeds. Deniespermanent/removable dental prosthetics. Last dental exam 2010.Denies swollen glands/limps, neck stiffness.
Thorax and Lungs
Denies history of lung disease, allergies, orasthms. Denies episodes of unexplained shortness of breath.
Denies “heart trouble”, high blood pressure,rheumatic fever, heart murmurs, irregular beat, palpitations, or chestpain/discomfort. No prior stress test or EKG.
Peripheral Vascular
Denies extremity edema, coldness, leg cramps,skin ulcers.
Regular diet. No swallowing difficulties. Denies problems
with nausea/vomiting, heartburn, or food intolerances. Regular diet.No recent change in weight. Denies chronic diarrhea, but has self-limiting episodes of diarrhea which he attributes to stress. Also reportsepisodic problems with hemorrhoids with blood on toilet paper andstreaking of passage of hard stool. States currently has a couple smallhemorrhoids with no bleeding. Denies history of jaundice, gall bladder,or liver disease.
Denies urinary frequency, hesitancy, incontinence, orburning with urination. History of passing 5mm kidney stone 2007. Ina long-term monogamous relationship. Denies sexual issues.
Denies thyroid problems, heat/coldintolerance, excessive hunger, thirst, or history of diabetes. Deniesconcerning bruising, ease of bleeding. No history of bloodtransfusions.
Denies trouble concentrating, nervousness, anxiety, orpanic attack. Denies difficulty falling or staying asleep. Occasional(once/week) getting out of bed earlier than waking time to urinate(associated with drinking fluids at night). Denies mood changes,hearing voices, frequent unhappiness, or desire to harm self or others.Denies nightmares, memory loss, or excessive life stresses. No recentdeaths in family or close friends.
Right ankle fracture (football, non-displaced) 1991.Occasional pain both knees, which he attributes to years of playingsports and not to a traumatic event. Denies other orthopedic injury orarthralgia.
Denies history of stroke, seizures orfrequent/incapacitating headache. Denies tremors.
ObjectiveGeneral Appearance
50 year-old male who is awake, alert, andcooperative. Clothing is well kept and appropriate for season. He isoriented to person, place, and time and answers all questionsappropriately. Appears stated age, appears to be healthy, and doesnot appear to be in any acute distress.
BP Right arm sitting. 152/92HR 72RR 16Sa02 99% on room air

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