Acute Asthma.Soap Note.

Name: 

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

“ .”

HPI: 

.

Current Medications:

PMHx:

Allergies:  

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

Family History

Social History

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nose/Mouth/Throat

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight   lb  

Temp -

BP

Height 5’1

Pulse

Respiration

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately.

Lab Tests

Special Tests- No ordered at this time.

 Diagnosis

 Differential Diagnoses

Diagnosis

Plan/Therapeutics

· Plan: 

· Medication –

· Education –

· Follow-up –