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You are here: Educational Career Guide > Medical Assistant Skill Review > Medical SOAP Note Examples
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The Four Parts of a SOAP Note
S - O - A - P
1.
SUBJECTIVE
— The
initial portion of the SOAP note format consists of
subjective observations. These are symptoms the
patient verbally expresses or as stated by a
significant other. These subjective observations
include the patient's descriptions of pain or
discomfort, the presence of nausea or dizziness and a
multitude of other descriptions of dysfunction,
discomfort or illness the patient
describes.
2. 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.
3. 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.
4. PLAN — The last part of the SOAP note is the
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 and follow-up
directions for the patient.
SOAP Note Examples
The below SOAP note examples
are as a medical assistant would enter them in a patient's
record.
Soap Note
Example 1:
Patient Name:
Robert Kryle DOB: 12/31/1961
Record No.
K-6112r809
Date:
09/09/1999
S—Pt. states that she has always been
overweight. She is very frustrated with trying to
diet. Her 20 year class reunion is next year and she
would like to begin working toward a weight loss goal
that is realistic. NKDA,
NKA.
O—WT = 210 lbs HT = 60 “ BW = 115 lbs
Chol = 255 BP = 120/75
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 one
week.
———————————————————————————
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 6
months
———————————————————————————
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
———————————————————————————
Soap Note Example
4:
Patient Name:
Robert Dreg 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
both hips, no swelling or
redness.
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.
———————————————————————————
Soap Note
Example 5:
Patient Name:
Paul Kessler DOB: 11/03/1961
Record No.
K-470pk624
Date:
21/8/2008
S—Mild burning with frequent
urination, a thin discharge that is worse in the A.M.,
irritation at the urinary 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.
———————————————————————————
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