At GPAShark.com, we specialize in providing high-quality SOAP Note Writing services to nursing students. SOAP notes are a systematic way to document patient care, ensuring all essential details are covered. Here’s a simple guide to help you understand and write effective SOAP notes:
Table of Contents
What is a SOAP Note?
SOAP stands for Subjective, Objective, Assessment, and Plan. It’s a structured method used by healthcare providers to document patient interactions and plan for their care.
Components of a SOAP Note
- Subjective (S):
- Chief Complaint (CC): The main reason for the patient’s visit.
- History of Present Illness (HPI): Detailed information about the chief complaint, including onset, duration, and characteristics.
- Medical History: Past medical conditions, surgeries, family history.
- Current Medications: List of medications the patient is currently taking.
- Allergies: Known allergies and reactions.
- Review of Systems (ROS): A systematic review of each body system to identify any other symptoms the patient may have.
- Objective (O):
- Vital Signs (VS): Blood pressure, heart rate, temperature, respiratory rate.
- Physical Exam Findings: Observable and measurable findings from the physical examination.
- Diagnostic Results: Results from laboratory tests, imaging studies, etc.
- Assessment (A):
- Diagnosis: Based on the subjective and objective data, provide a diagnosis.
- Differential Diagnosis: Other potential diagnoses considered.
- Plan (P):
- Treatment: Medications, therapies, surgeries planned.
- Further Tests: Additional tests or procedures required.
- Patient Education: Information and instructions provided to the patient.
- Follow-Up: Next steps, including when the patient should return for a follow-up visit.
SOAP notes examples
| Case Name | Subjective | Objective | Assessment | Plan |
| 14-year-old Male with ADHD SOAP Note Example | CC: Difficulty focusing and staying on task. HPI: Ongoing difficulties in maintaining attention, particularly in school settings. Current Medications: Methylphenidate. Allergies: None. ROS: Positive for difficulty focusing; negative for seizures. | VS: WNL. Mental Status Exam: Fidgety, cooperative, logical thought process. | ADHD, Combined Presentation. | Medication review, behavioral therapy, school support, follow-up in 1 month. |
| 35-year-old Female with Acute Bronchitis SOAP Note Example | CC: Cough and fever. HPI: Dry cough and fever for 3 days. Current Medications: None. Allergies: None. ROS: Positive for cough, fever; negative for chest pain. | Temp: 101°F, RR: 20, HR: 88. Lungs: Crackles in right lower lobe. | Acute Bronchitis. | Prescribe antibiotics, encourage fluids, rest, follow-up in 1 week. |
| 45-year-old Male with Knee Sprain SOAP Note Example | CC: Knee pain. HPI: Left knee pain for 2 weeks after a fall. Current Medications: Ibuprofen. Allergies: None. ROS: Positive for pain and swelling; negative for redness. | VS: WNL. Knee: Swelling, tenderness, reduced ROM. X-ray: No fracture. | Left Knee Sprain. | Rest, ice, compression, elevation (RICE), physical therapy. |
| 28-year-old Female with Migraine SOAP Note Example | CC: Headache. HPI: Intermittent, throbbing headaches for 1 month. Current Medications: None. Allergies: Penicillin. ROS: Positive for headache; negative for visual changes. | VS: WNL. Neuro Exam: Normal. HEENT: No abnormalities. | Migraine Headaches. | Prescribe triptans, advise headache diary, avoid triggers, follow-up in 2 weeks. |
| 50-year-old Male with Acute Appendicitis SOAP Note Example | CC: Abdominal pain. HPI: Sharp, lower right abdominal pain for 12 hours. Current Medications: Metformin. Allergies: None. ROS: Positive for pain, nausea; negative for vomiting. | VS: WNL. Abdomen: Tender RLQ, rebound tenderness. CBC: Elevated WBC. | Acute Appendicitis. | Refer to ER for surgical evaluation. |
| 60-year-old Female with COPD Exacerbation SOAP Note Example | CC: Shortness of breath. HPI: Increased SOB for 3 days. Current Medications: Albuterol. Allergies: None. ROS: Positive for SOB, cough; negative for chest pain. | VS: O2 sat 88% on RA, RR: 24. Lungs: Wheezing bilaterally. | COPD Exacerbation. | Prescribe steroids, antibiotics, nebulizer treatments, follow-up in 1 week. |
| 30-year-old Male with Acute Lumbar Strain SOAP Note Example | CC: Back pain. HPI: Lower back pain for 1 week after lifting heavy object. Current Medications: None. Allergies: None. ROS: Positive for pain, negative for numbness. | VS: WNL. Back: Tenderness L4-L5, reduced ROM. Straight leg raise: Negative. | Acute Lumbar Strain. | Rest, NSAIDs, physical therapy, follow-up in 2 weeks. |
| 25-year-old Female with Contact Dermatitis SOAP Note Example | CC: Rash. HPI: Itchy, red rash on arms for 3 days. Current Medications: None. Allergies: None. ROS: Positive for itching, negative for fever. | VS: WNL. Skin: Erythematous, maculopapular rash on forearms. | Contact Dermatitis. | Prescribe topical steroids, antihistamines, avoid irritants, follow-up in 1 week. |
| 55-year-old Male with Myocardial Infarction SOAP Note Example | CC: Chest pain. HPI: Chest pain radiating to left arm for 2 hours. Current Medications: Lisinopril. Allergies: None. ROS: Positive for pain, negative for SOB. | VS: BP 150/90, HR: 90. ECG: ST elevation. | Acute Myocardial Infarction. | Refer to ER for immediate evaluation and treatment. |
| 10-year-old Male with Acute Otitis Media SOAP Note Example | CC: Ear pain. HPI: Right ear pain and discharge for 2 days. Current Medications: None. Allergies: None. ROS: Positive for pain, discharge; negative for fever. | VS: WNL. Ear Exam: Red, bulging tympanic membrane, purulent discharge. | Acute Otitis Media. | Prescribe antibiotics, analgesics, follow-up in 1 week. |
| 40-year-old Female with Iron-Deficiency Anemia SOAP Note Example | CC: Fatigue. HPI: Chronic fatigue for 6 months. Current Medications: None. Allergies: None. ROS: Positive for fatigue; negative for weight loss, depression. | VS: WNL. Physical Exam: Normal. CBC: Anemia. | Iron-Deficiency Anemia. | Prescribe iron supplements, dietary counseling, follow-up in 1 month. |
| 70-year-old Male with BPPV SOAP Note Example | CC: Dizziness. HPI: Intermittent dizziness for 1 month. Current Medications: Hydrochlorothiazide. Allergies: None. ROS: Positive for dizziness; negative for syncope. | VS: BP 130/80, HR: 72. Neuro Exam: Normal. | Benign Paroxysmal Positional Vertigo (BPPV). | Prescribe vestibular rehabilitation exercises, meclizine, follow-up in 2 weeks. |
| 20-year-old Female with Streptococcal Pharyngitis SOAP Note Example | CC: Sore throat. HPI: Sore throat and fever for 2 days. Current Medications: None. Allergies: None. ROS: Positive for sore throat, fever; negative for cough. | VS: Temp 100.5°F, HR: 80. Throat Exam: Erythema, tonsillar exudates. | Streptococcal Pharyngitis. | Prescribe antibiotics, advise rest, fluids, follow-up in 1 week. |
| 65-year-old Female with Osteoarthritis SOAP Note Example | CC: Joint pain. HPI: Bilateral knee pain for 1 year, worse with activity. Current Medications: Acetaminophen. Allergies: None. ROS: Positive for pain, stiffness; negative for swelling. | VS: WNL. Knee Exam: Crepitus, reduced ROM. X-ray: Osteoarthritis. | Osteoarthritis. | Prescribe NSAIDs, physical therapy, consider steroid injections. |
| 22-year-old Male with Generalized Anxiety Disorder SOAP Note Example | CC: Anxiety. HPI: Generalized anxiety for 6 months. Current Medications: None. Allergies: None. ROS: Positive for anxiety, insomnia; negative for depression. | VS: WNL. Mental Status Exam: Anxious affect, normal cognition. | Generalized Anxiety Disorder. | Prescribe SSRIs, recommend cognitive-behavioral therapy, follow-up in 4 weeks. |
| 50-year-old Female with DVT SOAP Note Example | CC: Leg swelling. HPI: Swelling in left leg for 1 week. Current Medications: None. Allergies: None. ROS: Positive for swelling, negative for pain. | VS: WNL. Leg Exam: Non-pitting edema, erythema. Doppler US: DVT. | Deep Vein Thrombosis. | Prescribe anticoagulants, advise elevation, compression stockings, follow-up in 1 week. |
| 45-year-old Male with Hyperthyroidism SOAP Note Example | CC: Weight loss. HPI: Unintentional weight loss of 10 lbs in 2 months. Current Medications: None. Allergies: None. ROS: Positive for weight loss, negative for appetite changes. | VS: WNL. Physical Exam: Normal. Labs: Elevated TSH. | Hyperthyroidism. | Prescribe antithyroid medications, refer to endocrinologist, follow-up in 2 weeks. |
| 30-year-old Female with Giardiasis SOAP Note Example | CC: Diarrhea. HPI: Watery diarrhea for 3 days. Current Medications: None. Allergies: None. ROS: Positive for diarrhea, abdominal cramps; negative for fever. | VS: WNL. Abdomen: Soft, non-tender. Stool O&P: Positive for Giardia. | Giardiasis. | Prescribe metronidazole, advise hydration, dietary modifications, follow-up in 1 week. |
| 38-year-old Male with Plantar Fasciitis SOAP Note Example | CC: Heel pain. HPI: Right heel pain for 2 months, worse in the morning. Current Medications: Ibuprofen PRN. Allergies: None. ROS: Positive for heel pain, negative for swelling. | VS: WNL. Foot Exam: Tenderness at plantar fascia insertion. X-ray: No abnormalities. | Plantar Fasciitis. | Prescribe NSAIDs, recommend stretching exercises, orthotic inserts, follow-up in 4 weeks. |
| 27-year-old Female with Urinary Tract Infection SOAP Note Example | CC: Dysuria. HPI: Painful urination and increased frequency for 2 days. Current Medications: None. Allergies: None. ROS: Positive for dysuria, frequency; negative for fever. | VS: WNL. Urinalysis: Positive for leukocytes and nitrites. | Urinary Tract Infection. | Prescribe antibiotics, advise increased fluid intake, follow-up in 1 week. |
| 65-year-old Male with Alzheimer’s Disease SOAP Note Example | CC: Memory loss. HPI: Progressive memory decline over 1 year. Current Medications: Donepezil. Allergies: None. ROS: Positive for memory loss, negative for agitation. | VS: WNL. Mental Status Exam: MMSE score 20/30. Neuro Exam: Normal. | Alzheimer’s Disease. | Continue current medication, provide caregiver support, follow-up in 3 months. |
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FAQ: SOAP Notes Writing Services
Welcome to GPAShark.com! We specialize in providing high-quality SOAP Notes Writing Services for nursing students and healthcare professionals. Below are some frequently asked questions to help you understand our services better.
What are SOAP notes?
SOAP notes are a method of documentation employed by healthcare providers to write out notes in a patient’s chart. The acronym stands for Subjective, Objective, Assessment, and Plan.
Why are SOAP notes important?
SOAP notes ensure that patient care is well-documented, facilitating clear communication among healthcare providers and ensuring continuity of care.
Who can benefit from your SOAP Notes Writing Services?
Our services are beneficial for nursing students, medical students, healthcare providers, and anyone in the healthcare field who needs assistance with documentation.
What information do I need to provide to get my SOAP note written?
To write a comprehensive SOAP note, we need details on the patient’s chief complaint, history of present illness, medical history, current medications, allergies, review of systems, physical examination findings, diagnostic results, diagnosis, and treatment plan.
Are your writers qualified to write SOAP notes?
Yes, our team consists of experienced healthcare professionals and medical writers who are well-versed in clinical documentation and SOAP note writing.
Can I request revisions to my SOAP note?
Absolutely! We offer free revisions to ensure that the SOAP note meets your requirements and accurately reflects the patient’s condition and care plan.
Can you help with other types of medical documentation?
Yes, in addition to SOAP notes, we offer a wide range of medical documentation services, including patient histories, case reports, and more.
Are your services available internationally?
Yes, we provide our services to clients worldwide. Regardless of your location, we are here to assist you with your SOAP note writing needs.