SOAP NOTES FOR old: 60s to 74 year FEVER, COUGH AND HEADACHES R51. Headache; R50.8 Other specified fever; R05. Cough

Learning Goal: I’m working on a nursing report and need a sample draft to help me learn.

SOAP Note Template

Encounter date:________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age:_____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: ExcellentGoodFairPoor

Past Medical History

  • Major/Chronic Illnesses____________________________________________________
  • Trauma/Injury ___________________________________________________________
  • Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Family History____________________________________________________________

 

 

Social history:

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

 

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

 

Physical Exam

 

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____

General:HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

 

 

 

 

 

 

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

DiagnosisDiagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

DiagnosisDiagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

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