A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured,
soap note on a *Geriatric* patient (65+ years old)
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
Click here to access and download the SOAP Note TemplateDownload Click here to access and download the SOAP Note Template
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided.
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SOAP NOTE TEMPLATE Review the Rubric for more Guidance |
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Demographics |
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Chief Complaint (Reason for seeking health care) |
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History of Present Illness (HPI) |
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Allergies |
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Review of Systems (ROS) |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: |
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Vital Signs |
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Labs |
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Medications |
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Past Medical History |
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Past Surgical History |
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Family History |
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Social History |
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Health Maintenance/ Screenings |
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Physical Examination |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: |
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Diagnosis |
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Differential Diagnosis |
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ICD 10 Coding |
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Pharmacologic treatment plan |
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Diagnostic/Lab Testing |
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Education |
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Anticipatory Guidance |
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Follow up plan |
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Prescription |
See Below (scroll down) |
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References |
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Grammar |
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EA#: 101010101 STU Clinic LIC# 10000000 |
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Tel: (000) 555-1234 FAX: (000) 555-12222 |
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Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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SOAP |
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Demographics |
Patient (A.R.) is a 5-year-old white Hispanic male. Encounter Date: 03/37/2025 |
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Chief Complaint (Reason for seeking health care) |
Per mother “My son has been coughing and has had a runny nose for three days.” |
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History of Present Illness (HPI) |
As per mother’s report, the patient’s coughing and runny nose has an onset of 3 days ago. The present illness is located within the upper respiratory tract. The duration of the patient’s symptoms is persistent. Symptoms include a dry cough with nasal congestion and rhinorrhea. Symptoms are aggravated at night and can be relieved with warm fluids and honey that reportedly help a little bit. The timing of the symptoms is intermittent throughout the past three days but consistent overnight. Severity of the symptoms are mild to moderate, but mother reports that her son has thankfully not had any difficulty breathing. |
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Allergies |
As per the mother the patient has no known drug, environmental, food, herbal, and/or latex allergies. |
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Review of Systems (ROS) |
General: Mother admits a low-grade fever (100.2°F) noted yesterday; no chills or night sweats. HEENT: Mother admits the patient has congested nasal passages, clear rhinorrhea, dry throat, and mild ear discomfort. Neck: Mother denies swelling or stiffness of the neck. Lungs: Mother admits occasional dry cough, no wheezing or shortness of breath. Cardio: Mother denies palpitations or chest pain. Breast: Mother denies any breast tissue abnormalities with the patient. GI: Mother denies nausea, vomiting, diarrhea, or constipation. M/F genital: Mother denies any perineal abnormalities. GU: Mother denies dysuria or frequency changes. Neuro: Mother denies headaches, dizziness, or altered mental status. Musculo: Mother denies joint or muscle pain. Activity: Mother admits patient has slightly decreased energy level due to illness. Psychosocial: Mother admits patient is well-adjusted, no behavioral concerns. Derm: Mother denies any rashes or skin changes. Nutrition: Mother admits the patient’s appetite has slightly decreased. Sleep/Rest: Mother admits the patient is restless at night due to nasal congestion. LMP: N/A STI Hx: N/A |
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Vital Signs |
BP: 98/62 mmHg in a sitting position HR: 91 bpm RR: 23 breaths/min Temp: 99.8°F axillary SpO2: 98% on room air Weight: 21.2kg Height: 113cm CDC percentile 79.4% Pain: 0 using the FACES scale |
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Labs |
None reviewed at this time; clinical diagnosis based on symptoms. |
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Medications |
Acetaminophen 160 mg oral solution every 4-6 hours as needed PRN for fever. Ocean Nasal Spray sodium chloride nasal spray, 1 spray(s), nasal, as needed PRN for nasal congestion |
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