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SOAP Note Examples for Medical Assistants

A SOAP note is always written in a particular format; its purpose is to record information regarding a specific
patient's treatment in a consistent manner. The SOAP note format continues to be the format of choice in
ambulatory medical settings. The medical assistant is allowed to write the "S-part" exactly as stated by the
patient and is allowed to write the "O-part" exactly as observed into the patient's record. The medical assistant
is not allowed to write the "A-part" and not allowed to write the "P-part" into the patient's record.

SUBJECTIVE - The initial portion of the SOAP note format consists of subjective observations. These are
symptoms the patient verbally expresses or as stated by an accompanying relative or significant other. These
subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or
dizziness, when the problem first started and a multitude of other descriptions of dysfunction, discomfort, or
illness the patient describes.

OBJECTIVE - The next part of the format is the objective observation. These objective observations include
symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective
observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of
diagnostic tests.

ASSESSMENT - Assessment follows the objective observations. Assessment is the diagnosis of the patient's
condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not
be clear and could include several diagnosis possibilities.

PLAN -The last part of the SOAP note is the health care provider's plan. The plan may include laboratory
and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor
surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed
rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g.
elevate foot, RTO 1 week), and follow-up directions for the patient.
SOAP Note Abbreviations Key

Example SOAP Note 1:

Patient Name: Roberta Kryle DOB: 12/31/1961     Record No. K-6112r809      Date: 09/09/1999
S-CC: "I feel fat". Pt. states that she has always been overweight. She is very frustrated with trying to diet
because she always feels hungry. Her 20 year class reunion is next year and she would like to begin working
toward a weight loss goal that is realistic and within reach. NKDA, NKA.
O-WT = 210 lbs HT = 60 IBW = 115 lbs Chol = 255 BP = 129/75
A-Obese at 183% IBW, hypercholesterolemia
P-Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal:
Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and
smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in three
weeks.
---------------------- B. Ridman, CCMA M. Myer, MD

SOAP Note Example 2:

Patient Name: Lisa Brown DOB: 2/3/1960      Record No. B-583uw809      Date: 10/19/2001

S-Pt. here for weekly BP check, no complaints. NKDA, NKA.
O-BP 142/88; Atenolol 50 mg daily
A-hypertension controlled
P-Continue Atenolol; RTO 1 week
---------------------- M.T., CMA Carlos Monila, MD



SOAP Note Example 3:

Patient Name: Lisa Brown DOB: 2/3/1958      Record No. B-583uw809      Date: 04/21/2005

S-Pt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex
O-BP 142/88; Atenolol 50 mg daily
A-hypertension controlled
P-Continue Atenolol; RTO 6 months
--------------------- Daisy Rodriguez, CCMA Paula Klein, MD


SOAP Note Example 4:

Patient Name: Robert Dregg DOB: 09/17/1967      Record No. D-679dk978      Date: 12/4/2007

S-Pain in left hip x 3 months; worse when walking or doing exercise. NKDA.
O-Wt. 195 lb, Ht. 5'5'', normal ROM R leg, pain L leg in hip joint, no visib. swelling, or redness noted.
A-Possible osteoarthritis; R/O rheumatoid arthritis
P-blood work-sed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2
months.
--------------------- B. Ridman, CCMA Brenda D. Fisgers, MD


SOAP Note Example 5:
Patient Name: Paul Kessler DOB: 11/03/1961      Record No. K-470pk624      Date: 21/8/2008

S-Patient states: "Mild burning with urination, I have to go almost every 30 minutes, a thin liquid coming from
penis that is worse in the A.M. and irritation at the opening at tip of penis", NKA.
O-Discharge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is
positive.
A-Non-Gonorrheal Urethritis
P-Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for
10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices.
---------------------- R. W., RMA Ted Ricca, MD