Write a S.O.A.P Note

Date: June 12, 2012

Progress Notes

S. @ 1:00pm: Pt c/o abdominal pains for three days. Pt stated that she has been taking Tylenol 500 mg twice a day to relieve her pains. Pt denies nausea, vomiting and diarrhea. Pt reported that she believes she has a fever because she feels hot.

O. Wt 150, Ht 5’3, T 99.0, BP 120/70, P 86, R. 18------------------------------------Francine L. Rodgers, CMA

A. @ 1:30pm: for 3 days, examined pt today. Pt has been exhibiting some type of abdominal pain in the LLQ. No nausea and vomiting noted. No diarrhea and constipation. No recent weight gain or loss. Vitals normal. Denies bloody stools. Upon examination, felt a small lump in the abdominal area. Patient denies any injuries that could cause the lump in the RUQ. DX: R/O appendicitis.

P. Referred patient to radiology for x-ray of appendix. Pt will continue to take Tylenol to relieve pain. Pt will return in two weeks for follow-up and results of x-ray-------------------------------------------------------------------------------------------------------------------------John Connor, MD

Terms

BP – Blood Pressure

DX - Diagnosis

Ht - Height

LLQ – Lower Left Quadrant

P- Pulse

Pt – Patient

R- Respiration

T – Temperature

Wt- Weight

NVD- Nausea, Vomiting, and Diarrhea

RUQ- Right Upper Quadrant

c/o – Complains of

cc - Chief complaint

** Subjective information is also known as the patient’s chief complaint or reason for the office visit**