NR511_ihuman SOAP_Note_Template

SOAP Note Template

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Initials: Please enter initials here. Age: Please enter age here. Gender: Please enter gender here.
Height: Please enter height here. Weight: Please enter weight here. BP: Please enter blood pressure here. HR: Please enter heart rate here. RR: Please enter respiratory rate here. Temp: Please enter temperature here. SPO2: Please enter oxygen saturation here. Pain Rating: Please select a pain rating. Allergies (and reaction): Please enter allergies and reactions here.
Medication: Please enter medication here.

Food: Please enter food-related information here.
Environment: Please enter environmental information here.
History of Present Illness (HPI)
Chief Complaint (CC): Please enter the chief complaint here. The CC is a brief statement identifying why the patient is here, in the patient’s own words. For example, “headache,” not “bad headache for 3 days.” In some cases, a patient may have more than one complaint. For instance, if the patient presents with a cough and sore throat, identify which is the CC and which may be an associated symptom.
Onset: Please enter onset information here.
Location: Please enter location information here.
Duration: Please enter duration information here.
Characteristics: Please enter characteristics information here.
Aggravating Factors: Please enter aggravating factors here.
Relieving Factors: Please enter relieving factors here.
Treatment: Please enter treatment information here.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also, include over-the-counter (OTC) or homeopathic products.
Medication (Rx, OTC, or Homeopathic): Please enter medication information here.
Dosage: Please enter dosage here.
Frequency: Please enter frequency here.
Length of Time Used: Please enter the length of time used here.
Reason for Use: Please enter the reason for use here.

Past Medical History (PMHx) – Includes but is not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more information may be needed.

Social History (Soc Hx) – Includes but is not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion activities such as consistent seat belt use or the presence of working smoke detectors in the house.

Kaylee Hales I-Human Case Study SOAP Note: Evaluating and Managing Integumentary Conditions

Family History (Fam Hx) – Includes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Include the reason for the death of any deceased first-degree relatives. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis. Check the box next to each positive symptom and provide additional details.
Constitutional

If the patient denies all symptoms for this system, check here: ☐
Skin

If the patient denies all symptoms for this system, check here: ☐
HEENT

If the patient denies all symptoms for this system, check here: ☐
☐Fatigue: Please provide details here.

☐Weakness: Please provide details here.

☐Fever/Chills: Please provide details here.

☐Weight Gain: Please provide details here.

☐Weight Loss: Please provide details here.

☐Trouble Sleeping: Please provide details here.

☐Night Sweats: Please provide details here.

☐Other: Please provide details here.

☐Itching: Please provide details here.

☐Rashes: Please provide details here.

☐Nail Changes: Please provide details here.

☐Skin Color Changes: Please provide details here.

☐Other: Please provide details here.

☐Diplopia: Please provide details here.

☐Eye Pain: Please provide details here.

☐Eye Redness: Please provide details here.

☐Vision Changes: Please provide details here.

☐Photophobia: Please provide details here.

☐Eye Discharge: Please provide details here.

☐Earache: Please provide details here.

☐Tinnitus: Please provide details here.

☐Epistaxis: Please provide details here.

☐Vertigo: Please provide details here.

☐Hearing Changes: Please provide details here.

☐Hoarseness: Please provide details here.

☐Oral Ulcers: Please provide details here.

☐Sore Throat: Please provide details here.

☐Congestion: Please provide details here.

☐Rhinorrhea: Please provide details here.

☐Other: Please provide details here.

Respiratory

If the patient denies all symptoms for this system, check here: ☐
Neuro

If the patient denies all symptoms for this system, check here: ☐
Cardiac and Peripheral Vascular

If the patient denies all symptoms for this system, check here: ☐
☐Cough: Please provide details here.

☐Hemoptysis: Please provide details here.

☐Dyspnea: Please provide details here.

☐Wheezing: Please provide details here.

☐Pain on Inspiration: Please provide details here.

☐Sputum Production: Please provide details here.

☐Other: Please provide details here.

☐Syncope or Lightheadedness: Please provide details here.

☐Headache: Please provide details here.

☐Numbness: Please provide details here.

☐Tingling: Please provide details here.

☐Sensation Changes: Please provide details here.

☐Speech Deficits: Please provide details here.

☐Other: Please provide details here.

☐Chest Pain: Please provide details here.

☐SOB: Please provide details here.

☐Exercise Intolerance: Please provide details here.

☐Orthopnea: Please provide details here.

☐Edema: Please provide details here.

☐Murmurs: Please provide details here.

☐Palpitations: Please provide details here.

☐Faintness: Please provide details here.

☐Claudications: Please provide details here.

☐PND: Please provide details here.

☐Other: Please provide details here.

MSK

If the patient denies all symptoms for this system, check here: ☐

GI

If the patient denies all symptoms for this system, check here: ☐
GU

If the patient denies all symptoms for this system, check here: ☐
PSYCH

If the patient denies all symptoms for this system, check here: ☐
☐Pain: Please provide details here.

☐Stiffness: Please provide details here.

☐Crepitus: Please provide details here.

☐Swelling: Please provide details here.

☐Limited ROM: Please provide details here.

☐Redness: Please provide details here.

☐Misalignment: Please provide details here.

☐Other: Please provide details here.

☐Nausea/Vomiting: Please provide details here.

☐Dysphasia: Please provide details here.

☐Diarrhea: Please provide details here.

☐Appetite Change

: Please provide details here.

☐Heartburn: Please provide details here.

☐Blood in Stool: Please provide details here.

☐Abdominal Pain: Please provide details here.

☐Excessive Flatus: Please provide details here.

☐Food Intolerance: Please provide details here.

☐Rectal Bleeding: Please provide details here.

☐Other: Please provide details here.

☐Urgency: Please provide details here.

☐Dysuria: Please provide details here.

☐Burning: Please provide details here.

☐Hematuria: Please provide details here.

☐Polyuria: Please provide details here.

☐Nocturia: Please provide details here.

☐Incontinence: Please provide details here.

☐Other: Please provide details here.

☐Stress: Please provide details here.

☐Anxiety: Please provide details here.

☐Depression: Please provide details here.

☐Suicidal/Homicidal Ideation: Please provide details here.

☐Memory Deficits: Please provide details here.

☐Mood Changes: Please provide details here.

☐Trouble Concentrating: Please provide details here.

☐Other: Please provide details here.

GYN

If the patient denies all symptoms for this system, check here: ☐
Hematology/Lymphatics

If the patient denies all symptoms for this system, check here: ☐
Endocrine

If the patient denies all symptoms for this system, check here: ☐
☐Rash: Please provide details here.

☐Discharge: Please provide details here.

☐Itching: Please provide details here.

☐Irregular Menses: Please provide details here.

☐Dysmenorrhea: Please provide details here.

☐Foul Odor: Please provide details here.

☐Amenorrhea: Please provide details here.

☐LMP: Please provide details here.

☐Contraception: Please provide details here.

☐Other: Please provide details here.

☐Anemia: Please provide details here.

☐ Easy bruising/bleeding: Please provide details here.

☐ Past Transfusions: Please provide details here.

☐ Enlarged/Tender lymph node(s): Please provide details here.

☐ Blood or lymph disorder: Please provide details here.

☐ Other: Please provide details here.

☐ Abnormal growth: Please provide details here.

☐ Increased appetite: Please provide details here.

☐ Increased thirst: Please provide details here.

☐ Thyroid disorder: Please provide details here.

☐ Heat/cold intolerance: Please provide details here.

☐ Excessive sweating: Please provide details here.

☐ Diabetes: Please provide details here.

☐ Other: Please provide details here.

O: Objective

Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess.” Document pertinent positive and negative assessment findings. Pertinent positive findings are the “abnormal” findings, and pertinent negative findings are the expected normal findings. Separate the assessment findings accordingly and be detailed.
Body System Positive Findings Negative Findings
General: Please enter general findings here. Please enter general findings here.
Skin: Please enter skin findings here. Please enter skin findings here.
HEENT: Please enter HEENT findings here. Please enter HEENT findings here.
Respiratory: Please enter respiratory findings here. Please enter respiratory findings here.
Neuro: Please enter neuro findings here. Please enter neuro findings here.
Cardiovascular: Please enter cardiovascular findings here. Please enter cardiovascular findings here.
Musculoskeletal: Please enter musculoskeletal findings here. Please enter musculoskeletal findings here.
Gastrointestinal: Please enter gastrointestinal findings here. Please enter gastrointestinal findings here.
Genitourinary: Please enter genitourinary findings here. Please enter genitourinary findings here.
Psychiatric: Please enter psychiatric findings here. Please enter psychiatric findings here.
Gynecological: Please enter gynecological findings here. Please enter gynecological findings here.

Problem List
1. Please enter the first problem here. 6. Please enter the sixth problem here. 11. Please enter the eleventh problem here.
2. Please enter the second problem here. 7. Please enter the seventh problem here. 12. Please enter the twelfth problem here.
3. Please enter the third problem here. 8. Please enter the eighth problem here. 13. Please enter the thirteenth problem here.
4. Please enter the fourth problem here. 9. Please enter the ninth problem here. 14. Please enter the fourteenth problem here.
5. Please enter the fifth problem here. 10. Please enter the tenth problem here. 15. Please enter the fifteenth problem here.

A: Assessment

Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
Diagnosis ICD-10 Code Pertinent Findings
Please enter the first diagnosis here. Please enter the ICD-10 code for the first diagnosis here. Please enter pertinent findings for the first diagnosis here.
Please enter the second diagnosis here. Please enter the ICD-10 code for the second diagnosis here. Please enter pertinent findings for the second diagnosis here.
Please enter the third diagnosis here. Please enter the ICD-10 code for the third diagnosis here. Please enter pertinent findings for the third diagnosis here.

P: Plan

Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time,” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
Diagnostics: List tests you will order this visit
Test Rationale/Citation
Please enter diagnostic tests here. Please provide a rationale and citation for the diagnostic tests here.
Please enter diagnostic tests here. Please provide a rationale and citation for the diagnostic tests here.
Please enter diagnostic tests here. Please provide a rationale and citation for the diagnostic tests here.
Please enter diagnostic tests here. Please provide a rationale and citation for the diagnostic tests here.
Please enter diagnostic tests here. Please provide a rationale and citation for the diagnostic tests here.
Medications: List medications/treatments, including OTC drugs you will order, and “continue meds” if pertinent.
Drug Dosage Length of Treatment Rationale/Citation
Please enter medication information here. Please enter dosage information here. Please enter the length of treatment here. Please provide a rationale and citation for the medication here.
Please enter medication information here. Please enter dosage information here. Please enter the length of treatment here. Please provide a rationale and citation for the medication here.
Please enter medication information here.

Please enter dosage information here. Please enter the length of treatment here. Please provide a rationale and citation for the medication here.
Please enter medication information here. Please enter dosage information here. Please enter the length of treatment here. Please provide a rationale and citation for the medication here.
Please enter medication information here. Please enter dosage information here. Please enter the length of treatment here. Please provide a rationale and citation for the medication here.
Referral/Consults:
Please enter referral/consultation information here. Please provide a rationale and citation for the referral/consultation here.
Education:
Please enter education information here. Please provide a rationale and citation for the education here.
Follow Up: Indicate when the patient should return to the clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Please enter follow-up information here. Please provide a rationale and citation for the follow-up here.
References
Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting.
Please enter reference information here.

Food: Click or tap here to enter text. NR511_ihuman SOAP_Note_Template

Environment: Click or tap here to enter text.

(Rx, OTC, or Homeopathic)

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

☐Weakness Click or tap here to enter text.

☐Fever/Chills Click or tap here to enter text.

☐Weight Gain Click or tap here to enter text.

☐Weight Loss Click or tap here to enter text.

☐Trouble Sleeping Click or tap here to enter text.

☐Night Sweats Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Rashes Click or tap here to enter text.

☐Nail Changes Click or tap here to enter text.

☐Skin Color Changes Click or tap here to enter text.

NR511_ihuman SOAP_Note_Template

☐Other:

Click or tap here to enter text.

☐Eye Pain Click or tap here to enter text.

☐Eye redness Click or tap here to enter text.

☐Vision changes Click or tap here to enter text.

☐Photophobia Click or tap here to enter text.

☐Eye discharge Click or tap here to enter text.

☐Tinnitus Click or tap here to enter text.

☐Epistaxis Click or tap here to enter text.

☐Vertigo Click or tap here to enter text.

☐Hearing Changes Click or tap here to enter text.

☐Oral Ulcers Click or tap here to enter text.

☐Sore Throat Click or tap here to enter text.

☐Congestion Click or tap here to enter text.

☐Rhinorrhea Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

☐Hemoptysis Click or tap here to enter text.

☐Dyspnea Click or tap here to enter text.

☐Wheezing Click or tap here to enter text.

☐Pain on Inspiration Click or tap here to enter text.

☐Sputum Production

Choose an item.

Choose an item.

Choose an item.

☐Other: Click or tap here to enter text.

☐Headache Click or tap here to enter text.

☐Numbness Click or tap here to enter text.

☐Tingling Click or tap here to enter text.

☐Sensation Changes

Choose an item.

☐Speech Deficits Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐SOB Click or tap here to enter text.

☐Exercise Intolerance Click or tap here to enter text.

☐Orthopnea Click or tap here to enter text.

☐Edema Click or tap here to enter text.

☐Murmurs Click or tap here to enter text.

☐Faintness Click or tap here to enter text.

☐Claudications Click or tap here to enter text.

☐PND Click or tap here to enter text.

☐Other: Click or tap here to enter text.

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

☐Stiffness Click or tap here to enter text.

☐Crepitus Click or tap here to enter text.

☐Swelling Click or tap here to enter text.

☐Limited ROM Choose an item.

☐Redness Click or tap here to enter text.

☐Misalignment Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Dysphasia Click or tap here to enter text.

☐Diarrhea Click or tap here to enter text.

☐Appetite Change Click or tap here to enter text.

☐Heartburn Click or tap here to enter text.

☐Blood in Stool Click or tap here to enter text.

☐Abdominal Pain Click or tap here to enter text.

☐Excessive Flatus Click or tap here to enter text.

☐Food Intolerance Click or tap here to enter text.

☐Rectal Bleeding Click or tap here to enter text.

☐Other:

☐Dysuria Click or tap here to enter text.

☐Burning Click or tap here to enter text.

☐Hematuria Click or tap here to enter text.

☐Polyuria Click or tap here to enter text.

☐Nocturia Click or tap here to enter text.

☐Incontinence Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Anxiety Click or tap here to enter text.

☐Depression Click or tap here to enter text.

☐Suicidal/Homicidal Ideation Click or tap here to enter text.

☐Memory Deficits Click or tap here to enter text.

☐Mood Changes Click or tap here to enter text.

☐Trouble Concentrating Click or tap here to enter text.

☐Other: Click or tap here to enter text.

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

If patient denies all symptoms for this system, check here:  ☐

☐Discharge Click or tap here to enter text.

☐Itching Click or tap here to enter text.

☐Irregular Menses Click or tap here to enter text.

☐Dysmenorrhea Click or tap here to enter text.

☐Foul Odor Click or tap here to enter text.

☐Amenorrhea Click or tap here to enter text.

☐LMP: Click or tap here to enter text.

☐Contraception Click or tap here to enter text.

☐Other:Click or tap here to enter text.

☐ Easy bruising/bleeding Click or tap here to enter text.

☐ Past Transfusions Click or tap here to enter text.

☐ Enlarged/Tender lymph node(s) Click or tap here to enter text.

☐ Blood or lymph disorder Click or tap here to enter text.

☐ Other Click or tap here to enter text.

☐ Increased appetite Click or tap here to enter text.

☐ Increased thirst Click or tap here to enter text.

☐ Thyroid disorder Click or tap here to enter text.

☐ Heat/cold intolerance Click or tap here to enter text.

☐ Excessive sweating Click or tap here to enter text.

☐ Diabetes Click or tap here to enter text.

☐ Other Click or tap here to enter text.

  Choose an item.

Click or tap here to enter text.

Click or tap here to enter text.

  Choose an item.

Click or tap here to enter text.

Click or tap here to enter text NR511_ihuman SOAP_Note_Template.

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NR511_ihuman SOAP_Note_Template

NR511_ihuman SOAP_Note_Template

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Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting.