SOAP notes are a standard method used by healthcare professionals to document patient care. Here are some examples of SOAP notes:
Example 1: Patient with Upper Respiratory Infection
S: Patient reports sore throat, congestion, and cough for the past 4 days. O: Vital signs are within normal limits. Lungs are clear to auscultation. Nasal passages are congested with clear discharge. Throat is erythematous with no exudate. No lymphadenopathy is noted. A: Upper respiratory infection P: Recommend symptomatic treatment with over-the-counter decongestants, antihistamines, and cough suppressants. Encourage patient to rest and stay hydrated. Advise patient to follow up if symptoms persist or worsen.
Example 2: Patient with Type 2 Diabetes
S: Patient reports difficulty controlling blood sugar levels. O: Vital signs are within normal limits. Blood glucose level is 185 mg/dL. A1C is 8.5%. Patient has lost 5 pounds since last visit. Patient reports compliance with medication regimen. A: Uncontrolled type 2 diabetes P: Increase dosage of current medication. Encourage patient to maintain a healthy diet and exercise regularly. Schedule follow-up appointment in 3 months for re-evaluation.
Example 3: Patient with Depression
S: Patient reports feeling sad and hopeless for the past month. O: Vital signs are within normal limits. Patient has flat affect and decreased energy. No suicidal ideation is reported. A: Major depressive disorder P: Refer patient to a mental health specialist for further evaluation and treatment. Discuss the risks and benefits of antidepressant medication. Encourage patient to participate in counseling and support groups. Schedule follow-up appointment in 2 weeks for re-evaluation.
Example 4: Patient with Hypertension
S: Patient reports occasional headaches and fatigue. O: Vital signs are within normal limits except for blood pressure, which is 150/95 mmHg. Heart and lung sounds are normal. No peripheral edema is present. A: Hypertension P: Initiate treatment with an antihypertensive medication. Encourage patient to adopt a healthy lifestyle, including a low-sodium diet and regular exercise. Schedule follow-up appointment in 2 weeks for re-evaluation.
Example 5: Patient with Knee Pain
S: Patient reports knee pain that started after a fall. O: Vital signs are within normal limits. Knee joint is swollen and tender to palpation. No deformities or instability are noted. Patient has limited range of motion. A: Knee contusion with possible ligamentous injury P: Order X-ray to rule out any bone fractures. Prescribe pain medication and recommend rest, ice, compression, and elevation (RICE) for the first 48 hours. Refer patient to an orthopedic specialist for further evaluation and management.