This sample SOAP note demonstrates a format commonly used by Nurse Practitioners (NPs). Remember that specific requirements may vary based on your practice, state regulations, and electronic health record (EHR) system. This is a template and should be adapted to reflect the individual patient's situation. This is not a substitute for professional medical advice. Always consult relevant guidelines and resources for proper documentation.
Patient: Jane Doe, DOB: 01/01/1980 Date: October 26, 2023 Chart Number: 1234567
S: Subjective
- Chief Complaint (CC): "Persistent cough and shortness of breath for two weeks."
- History of Present Illness (HPI): Patient reports a non-productive cough for the past two weeks, worsening over the last three days. She also complains of shortness of breath, especially with exertion. Denies fever, chills, or chest pain. Reports feeling increasingly fatigued. She states that she has tried over-the-counter cough suppressants with minimal relief. No known allergies. Patient denies recent travel or exposure to sick individuals. Smoker (1 pack per day for 15 years).
- Past Medical History (PMH): Hypertension (HTN), controlled with Lisinopril 20mg daily. No known surgical history.
- Family History (FH): Father with history of heart disease, mother with history of type 2 diabetes.
- Social History (SH): Patient reports smoking 1 pack of cigarettes per day for 15 years. Denies alcohol or illicit drug use. Works as a teacher. Reports moderate stress levels.
- Medications: Lisinopril 20mg daily. Over-the-counter cough suppressant (brand name and dosage specified).
- Allergies: NKDA (No known drug allergies)
O: Objective
- Vital Signs: BP 138/88 mmHg, HR 92 bpm, RR 22 breaths/min, Temp 98.6°F (oral), SpO2 95% on room air.
- Physical Exam: Lungs: Auscultation reveals bilateral rhonchi. Heart: Regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen: Soft, non-tender, no hepatosplenomegaly. Skin: Warm, dry, and intact.
- Diagnostic Tests: None ordered at this time. Consideration given to Chest X-ray based on findings.
A: Assessment
- Possible Diagnosis: Acute bronchitis, considering patient's smoking history and symptoms. Other possibilities include pneumonia or COPD exacerbation, which require further investigation.
P: Plan
- Diagnostic Testing: Order Chest X-ray to rule out pneumonia or other pulmonary pathology.
- Treatment:
- Medication: Prescribe Albuterol inhaler for bronchodilation (if indicated by further assessment) and consider a broader-spectrum antibiotic if chest x-ray suggests bacterial pneumonia (Amoxicillin or Doxycycline, for example - prescription based on local guidelines and patient factors). Continue Lisinopril as prescribed. Cough suppressant as needed.
- Patient Education: Instruct patient on proper inhaler technique (if prescribed). Educate on smoking cessation resources and benefits. Advise patient to increase fluid intake and get plenty of rest. Schedule follow-up appointment in one week to review results and assess response to treatment.
- Referral: Consider referral to pulmonology if symptoms persist or worsen despite treatment.
Note: This is a sample SOAP note, and the specific details will vary depending on the patient's presentation. Always use your professional judgment and adhere to established guidelines and protocols. Remember to document thoroughly and accurately.
