S.O.A.P. Note Template CASE ID# Tina Jones

What brought you here today…(eg. headache) Patient states that she is here for a physical exam as she is starting a new job. History of Pre s e nt Illn e s s Chronological order of events, state of health b ...

What brought you here today…(eg. headache) Patient states that she is here for a physical exam as she is starting a new job. History of Pre s e nt Illn e s s Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient presented for a pre-employment physical for insurance purposes. She is starting a new job as an accounting clerk for Smith, Stewart, Silver, and Company. She states that she feels “all of my health stuff is better now. I feel like my diabetes is in control, I’m in better shape, I’m eating healthier. I’m less stressed. Things are going really well.” She reports that she last saw her primary care physician 5 months ago and was started on Metformin for her diabetes. She states that when she quit taking Metformin before it made her feel sick and gassy, now she eats yogurt and it seems to help. She has since lost 10 pounds by eating better, she is active in a blog for diabetics where she finds new recipes to try. She is exercising, walking 30-40 minutes 4-5 times a week and goes swimming at the Y once a week also. Since her last visit she has been to the eye doctor and was prescribed glasses which she wears. She has also visited a dentist five months ago, and no cavities or problems were found at that visit. She has also visited an OBGYN and was diagnoses with PCOS for which she was started on YAZ, 4 months ago. Her cramps have been much less since starting the birth control and her menstrual cycles are regular coming every 4 weeks and lasting 5 days. She visited an eye doctor 3 months ago and received glasses for her near-sightedness. Her headaches have been fewer and she has not had one for 6 months. She no longer has back pain, since she hurt her back and was seen in our clinic, she went to physical therapy and completed their recommended stretches and exercises. The sore that she had on her foot has healed and she has no recurrent problems from that. She was also started on Flovent daily and since starting that medication she has experienced a reduction in her asthma symptoms. She has only had to use her rescue inhaler once in the last three months when she visited a friend who had a cat that she is allergic to. She no longer has a problem with her asthma when climbing stairs. She no longer has sleeping problems that were associated with her stress. She has not had any heart palpitations since she stopped drinking energy drinks and excessive caffeine. She is much happier and looking forward to her new job, new apartment, and new relationships. Location Duration Character Aggravating/associate d factors Relieving factors Temporal factors – other things going on Severity P a st M e dic al History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Adult Illnesses: PCOS, Diabetes Mellitus II, Near-sightedness, Asthma (diagnosed at age of 2 ½), Gerd Childhood Illnesses: Chicken pox