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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

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!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.