Title: Reading: (CU1 M2) SOAP Example
Course: SkillsCom CMA 111 16.0 > Section: Credit Unit 1 Module 2

Review the document linked below for the standard SOAP note format. It is suggested that you print it out for future reference.

The Soap Note Format (Google Doc)

The goal of a SOAP note is to document the physician - patient encounter in a systematic way. With that in mind, compare the standard format to the SOAP note example shown below. How is it the same? How is it different?

One of the things that you must remember is that often documentation "in the real world" does not quite meet the standard of the ideal.  There are many reasons why this is so and we will discuss those later, but in the meantime, familiarize yourself with the format, components, and elements of a SOAP note.

SOAP Style Note Example

Clem Cadiddlehopper  6/17/1970

1/14/2016

Subjective:

Patient comes in today in generally good condition.  Patient has been diagnosed with htn since 2011.  Relatively well controlled on lisinopril 10 mg/qd.  Pt. reports no headaches or dizziness.

Patient reports no smoking.  Pt. quit smoking in 2013 with 30 pack-year history.  (15 years x 2 ppd).

Patient reports pain level today is 3/10.  Patient last took pain medication and muscle relaxant at 0600 this morning. Patient reports good muscle response lately, very little shaking or tremor.

Patient reports good days and bad days over the past month with rheumatoid pain.  Patient reports that using tincture, mild exercise (walking), and rest all help his rheumatoid pain level.  Patient reports that pain is worst in the evening after a day with physical exertion (yardwork, heavy exercise, etc).  Patient reports concentrated pain in both knees due to bilateral knee surgery in 2003.  Patient still managing on ibuprofen 800 mg/day.

Objective: Vitals: BP 146/94, P = 86, R = 18, O2 sat = 97%, 220 lbs, 64”

Auscultation of chest for heart sounds normal.  Auscultation of lungs normal in all four quadrants.  All major joints are examined by palpation.  General 2+ edema, hypertrophy, and nodular irregularity in all large joints with particular degeneration in knees, hands, and fingers.

Assessment:

1. hypertension, well controlled

2. rheumatoid arthritis

3. MS, doing well

Plan: continue patient on lisinopril, work on diet and exercise

Patient to continue using THC tincture (approximately 8-12 teaspoons per day) and Flexeril occasionally for pain and tremor.  Continue as needed.  Contact the office if any problems or additional pain.  Continue ibuprofen for pain and inflammation…. (consider biologics during next visit) Patient RTO in one month.