Write a S.O.A.P Note

Complete the following chart typing information that should be included in the S.O.A.P format (for example, 1. Weight 160 pounds is objective information)

1. Weight 160 pounds, Height is 5’3, and Blood Pressure is 118/80

2. A complaint of a sore throat for one week.

3. Return in two weeks for follow-up

4. Temperature is 103

5. Amoxicillin 500mg to take twice a day for two weeks

6. A wound on left arm

7. Examination by Physician

8. Pulse is 78

9. Respiration is 19

10. Patient reported nausea for two days

11. Patient denied vomiting and diarrhea

Part II:

Answer the following questions:

1. In your own words, define “chief complaint”?

2. What is the purpose of a progress note?

3. What part of a S.O.A.P note can a medical assistant document in?

4. Why is documentation important in a health care environment?

5. Write a sample of a Medical Assistant’s portion of a progress note in the chart below.