SOAP Note Template
Initials: E.P. Age: 78 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 2 120lbs 110/
70
92 16 37.0C 99% Medication: NKDA
Food: Denies
Environment: Latex (itchy skin rash) dx at
...
SOAP Note Template
Initials: E.P. Age: 78 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
5’ 2 120lbs 110/
70
92 16 37.0C 99% Medication: NKDA
Food: Denies
Environment: Latex (itchy skin rash) dx at age 54
History of Present Illness (HPI)
Chief Complaint (CC) “Belly pain” CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset 5 days ago
Location Lower abdomen
Duration Constant. Worse when moving or when eating. ( worse 2-3 days)
Characteristics Constant. Dull and crampy. Generalized pain that stays in one place. (Last BM
5 days ago, non- radiating worsedn over 2-3 days) (Add associated char
diarrhea, last BM)
Aggravating Factors Moving or after eating (put how it helped: little help )
Relieving Factors Resting and not moving ( put the degree of improvement what the pain is at
after intervention)
Treatment None (sips of water no help, Anything they did even if tx did not work)
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Accupril (research med side
effect coud be a DDX)
10mg Daily 24 yrs Hypertension
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