SOAP Note

Encounter date: ________________________

SOAP Adult

Patient Initials: __________ Gender: Male____ Female___ Transgender ____ Age: _____

Race: __________________

Chief Complaint: ________________________________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies (Drug/Food/Environmental/Herbal):____________________________________________________________________________________________________________________________________________________________________________________________________________ Current perception of Health: Excellent Good Fair Poor

PMH: ________________________________________________________________________

PSH: ________________________________________________________________________

Hospitalizations: ______________________________________________________________

Current Meds: ______________________________________________________________

Family History:_______________________________________________________________

Social history: __Married __Widowed __Single __ Divorced __Cohabitating Partner

Lives: __Home __Alone __ Family __Caretaker __ACLF __ SNF ___Other:

Smoke: ______________ETOH: ________________ Recreational Drug Use: _____________

Immunization HX: Please Document Date of Immunization or Date of Disease.

Immunizations	Pneumovac	HPV	HEP B	MMR	Varicella	TD/Tdap	FLU	Other:
	DATE:_____	DATE:___	1.	1.	1.
			2.	2.	2.
			3.
Disease

Review of Systems:

General_______________________________________________________________________

HEENT_______________________________________________________________________

Neck________________________________________________________________________

Lungs ________________________________________________________________________

Cardiovascular ________________________________________________________________

Breast ________________________________________________________________________

GI ___________________________________________________________________________

Male/female genital _____________________________________________________________

GU __________________________________________________________________________

Neuro_________________________________________________________________________

Musculoskeletal________________________________________________________________

Activity & Exercise _____________________________________________________________

Psychosocial ___________________________________________________________________

Derm_________________________________________________________________________

Nutrition ______________________________________________________________________

Sleep/Rest ____________________________________________________________________

LMP_____________

Physical Exam

BP__________TPR_______ ________Ht. ________ Wt. _________________ Wt. Change____ BMI_____________ O2 SAT%__________________

General_______________________________________________________________________

HEENT_______________________________________________________________________

Neck_________________________________________________________________________

Pulmonary_____________________________________________________________________

Cardiovascular_________________________________________________________________

Breast________________________________________________________________________

Abdomen______________________________________________________________________

Rectal________________________________________________________________________

Male/female genital_____________________________________________________________

Musculoskeletal________________________________________________________________

Neuro_________________________________________________________________________

Derm_________________________________________________________________________

Psych_________________________________________________________________________

Misc._________________________________________________________________________

Assessment:

Significant Data/Contributing Dx/Labs/Misc

Differential Diagnoses

1.

2.

3.

Diagnoses

1.

2.

3.

Plan

Diagnosis # 1

Diagnostic:

Therapeutic:

Educative:

Referrals:

Follow-up:

Diagnosis # 2

Diagnostic:

Therapeutic:

Educative:

Referrals:

Follow-up:

Diagnosis # 3

Diagnostic:

Therapeutic:

Educative:

Referrals:

Follow-up:

Signature_____________________________________________________________________

Cite current evidenced based guideline(s) used to guide careMandatory)

1._____________________________________________________________________

DEA#: 101010101 Barry University LIC# 1010101010101

College of Nursing Clinic

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age _______________

Address: ________________________________________ Allergies: _____________________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________