SOAP notes examples

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:

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

1. 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.
2. 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.
3. Assessment (A):
   • Diagnosis: Based on the subjective and objective data, provide a diagnosis.
   • Differential Diagnosis: Other potential diagnoses considered.
4. 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

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