SOAP note example for advanced nursing PDF

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Summary

This sample soap note is a great way to learn the appropriate layout for future soap notes as providers, gives clear outline of what to include and where...

Description

Subjective Chief Complaint: “I am always thirsty and hungry. I drink so much water during the day, and because of that, I always have to urinate. My eyesight is blurry lately.” History of Present Illness (HPI): R.G. is a 51-year-old male complaining of polyphagia, polydipsia, polyuria, and change in eye site. The patient reports that these symptoms started about one month ago, and no matter how much he drinks, nothing relieves his excessive thirst. Patient reports having no known drug allergies and denies taking any medications.

Allergies: None Current Medications: None Past Medical History (PMH): None Psychosocial and Family History: Father has Type II Diabetes Mellitus. Social History/Habits: Patient denies use of tobacco and illicit drugs. Patient reports drinking socially, about 3-4 times a month. Patient is an accountant, and reports spending much of his day at a desk. Because of the long hours he works, he is not motivated to exercise. Vaccination Hx: Vaccinations up to date Review of Systems: R.G. reports excessive hunger, thirst, and urination that began about one month ago. General: Patient states he has gained about 10 pounds within the last three months. Denies fever, chills, weakness, and weight loss. Reports occasional dizziness. HEENT: Head: Denies head injury, headache, and change in LOC. Eyes: Patient does not wear contact lens or glasses. Denies diplopia. Ears: Denies hearing loss, tinnitus, ear drainage, and ear pain. Nose: Denies nasal drainage, sinus pressure, itching, and sneezing. Throat/Neck: Denies sore throat, hoarseness, neck pain, and difficulty swallowing. Gastrointestinal: Denies abdominal pain, flatulence, nausea, vomiting, and diarrhea. Genitourinary: Denies hematuria, dysuria, and urine incontinence.

Musculoskeletal: Denies recent falls and pain. Skin: Denies rashes, pruritis, and changes in skin coloration. Objective Vital signs: HR: 78; BP: 140/90; RR: 20; SpO2: 99%; T: 98.0 degrees Fahrenheit, oral; Height: 5 ft 10 in; Weight: 210 pounds, BMI: 30.1; Pain reported 0/10. Physical exam General: Patient accompanied by his wife. Patient is alert and oriented x4. Patient appears to be in no apparent distress. Neurologic: Alert, oriented to person, place, time, and situation. Sensation to bilateral upper and lower extremities intact. 5/5 in all extremities. HEENT: Head: Normocephalic and symmetric, non-tender. No masses noted. Normal hair distribution noted. No pain with palpation of frontal or maxillary sinuses. Eyes: Extraocular eye movements intact. Patient demonstrates satisfactory peripheral fields by confrontation in both OD and OS. Pupils are equal, round, and reactive to light bilaterally. No nystagmus, conjunctival infection, or icterus noted. Visual acuity OD 20/40, OS 20/40. Ears: Bilateral ear canals patent, no erythema, exudate, or edema noted. Bilateral tympanic membranes intact. Nose: Patient’s septum is midline. Nasal mucosa moist. Mouth: Oral mucosa moist, no lesions noted. No obvious caries or periodontal disease. No gingival inflammation noted. Throat/Neck: No thyroid masses, thyroid swelling, jugular vein distension, and cervical lymphadenopathy noted. Respiratory: No dyspnea or use of accessory muscles observed. Chest rise symmetrical with respirations. Lung sounds clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1 and S2 on auscultation. No murmur or gallop noted. Capillary refill...