soap routine
TRANSCRIPT
-
7/25/2019 Soap Routine
1/3
Frontier Nursing University
Samples of SOAP Notes
Template for Episodic Visit
S: Chief complaint (CC): It is often helpful to use the patients report in quotation marks
here (i.e., I am having my perio t!ice a month.").
#istory of $resent Illness (#$I): Inclue onset, uration, progression, timing, amount,things that aggravate, things that relieve, treatments alreay trie, previous history of
similar symptoms, etc. %lso !oul inclue pertinent negatives.
$ast &eical #istory ($): Inclue any pertaining to the chief complaint or that
!oul affect treatment plan.Current &eications: Inclue all an ont forget to ask a'out alternative remeies.
%llergies
$sychosocial an amily #istory: Inclue any that pertains to the chief complaint or
that !oul affect treatment plan.Social #istory#a'its: Inclue use of to'acco, rugs an alcohol as !ell as social
history that may affect the treatment plan.
*: +ital signs if they are not liste else!here on this page.
eneral: Is the patient an-ious, nervous, or in pain /oes she look oler than state
age Can use 0%/ (no apparent istress).$hysical 1-am: Inclue only those systems pertaining to the chief complaint.
*rgani2e 'y systems an list in hea to toe orer.
/iagnostic: 3ist results that you have (la', -4ray, etc.).
%: /iagnosis: 5ritten at your level of unerstaning of the pro'lem an 'ase on the
su'6ective an o'6ective ata that you have presente.
$: 7) /iagnostic (la', -4ray, 18, other) that you plan for this patient.
9) reatment
;) 1ucation
-
7/25/2019 Soap Routine
2/3
-
7/25/2019 Soap Routine
3/3
!reast Exam "ocumentation
0ormal 1-am: Si2e (if remarka'le). Symmetric. 0ipples (num'er, placement, inversion,
ischarge). Skin changes (rashes, lesions, impling, retraction). 0ote masses or
tenerness.
/escription of a &ass: 3ocation, si2e, shape, consistency, mo'ility, istinctness, nipple,skin over lump, tenerness to palpation, lymphaenopathy.
Pelvic Exam "ocumentation
1-ternal enitalia:#air istri'ution, la'ia ma6ora an minora, Aartholins an Skenes glans (often groupe
!ith urethra an a''reviate A@S), hymen, introitus, perineum.
0ote any masses, lesions, e-coriation, erythema, tenerness or ischarge.
Internal enitalia:
+agina: Color, rugation, tone. 0ote cystocele, rectocele, ischarge.Cervi-: Color, os, position, te-uture, mo'ility. 0ote lesions, ischarge, C&.@terus: $osition, si2e, mo'ility. 0ote masses or tenerness.
%ne-ae: Si2e. 0ote masses or tenerness.