Generic SOAP Note

Musculoskeletal System
(Please note this is only an example of what can be documented.)
01/21/2014

1600

CC

HPI

USE OLD CARTS

Social history -FED TACOS

Use SMASH FM

ROS:

General: No fever, chills, night sweats, insomnia, weight loss, gain.

HEENT: + headaches, negative photophobia, no visual or hearing changes, ear pain,

rhinorrhea, sore throat, sinus pain.

GI: No N/V/D, constipation, appetite changes, dyspepsia, dysphagia, no changes in stool color

Cardiac: No chest pain, palpitations, syncope, pain with deep inspiration

Respiratory: No SOB, cough, sputum production

GU: No incontinence, dysuria, frequency or hesitancy

MSK: No joint pain, weakness, swelling

Neurology: No dizziness, numbness of extremities, LOC, forgetfulness, tremors

Objective Section

98.6,88,20, 140/90

Alert and oriented to person, place and time (A&Ox3). WNWD male, NAD.

MSK Extremities: (BUE)skin warm and dry without lesions, lacerations ecchymosis or
erythema, Cap refill <3 sec. radial and ulnar pulses intact

Muscle strength 5/5. Symmetrical without atrophy

Sensory -Sensation to superficial, dull and light touch, and vibration intact
All deep tendon reflexes intact are (DTR’s) biceps, triceps and brachioradialis are 2+.

Range of Motion in shoulder, elbow and wrist is without restriction

BLE: As above if you are assessing BLE.

Special Testing: Negative Spurlings, Lhermittee’s, + Hawkins Left shoulder

OMM: Cervical spine - Full active ROM, Structurally no mal-alignment noted. No TART. C3-
7, T1-T12

Plan

Use the MOTHERR acronym.