A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured,

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

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:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

SOAP

Demographics

Patient (A.R.) is a 5-year-old white Hispanic male.

Encounter Date: 03/37/2025

Chief Complaint (Reason for seeking health care)

Per mother “My son has been coughing and has had a runny nose for three days.”

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.

Allergies

As per the mother the patient has no known drug, environmental, food, herbal, and/or latex allergies.

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

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

Labs

None reviewed at this time; clinical diagnosis based on symptoms.

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

Past Medical History

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