This example demonstrates a well-structured SOAP note for a Nurse Practitioner (NP) encounter. Remember, this is a sample and should not be used as a direct template for patient care. Always adhere to your institution's guidelines and legal requirements for documentation. This example focuses on a common presentation, but the specifics will vary greatly depending on the patient's condition.
Patient: Jane Doe, 45-year-old female
Date: October 26, 2023
Time: 10:00 AM
S: Subjective
- Chief Complaint (CC): "Persistent cough and shortness of breath for two weeks."
- History of Present Illness (HPI): Patient reports a persistent, non-productive cough for the past two weeks, accompanied by shortness of breath, particularly with exertion. She denies fever, chills, or chest pain. She reports worsening symptoms over the past few days. She denies recent travel or exposure to sick individuals. She has a history of seasonal allergies, typically managed with over-the-counter medications. She denies tobacco use but reports occasional alcohol consumption (1-2 glasses of wine per week).
- Past Medical History (PMH): Seasonal allergies, hypertension (well-controlled with Lisinopril 20mg daily).
- Past Surgical History (PSH): None.
- Medications: Lisinopril 20mg daily. Over-the-counter cetirizine as needed for allergies.
- Allergies: NKDA (No Known Drug Allergies)
- Family History (FH): Mother with hypertension, father with history of heart disease.
- Social History (SH): Employed as a teacher, married, two adult children. Reports moderate stress levels related to work.
O: Objective
- Vital Signs: BP 130/80 mmHg, HR 90 bpm, RR 20 breaths/min, Temp 98.6°F (oral), SpO2 96% on room air.
- General Appearance: Alert and oriented, appears slightly fatigued.
- HEENT: Normal.
- Lungs: Clear to auscultation bilaterally except for scattered wheezes in the lower lobes.
- Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
- Abdomen: Soft, non-tender, no hepatosplenomegaly.
- Skin: Warm, dry, and intact.
A: Assessment
- Possible acute bronchitis: Given the persistent cough, shortness of breath, and presence of wheezes, acute bronchitis is the most likely diagnosis. The absence of fever and significant chest pain makes pneumonia less likely.
- Possible exacerbation of seasonal allergies: The patient’s history of seasonal allergies and the timing of the symptoms warrant consideration of an allergy exacerbation contributing to her respiratory symptoms.
- Hypertension: Well-controlled with current medication regimen.
P: Plan
- Diagnostics: Chest X-ray to rule out pneumonia. Spirometry to assess lung function and consider the contribution of bronchospasm.
- Treatment:
- Albuterol inhaler: Two puffs every four hours as needed for shortness of breath.
- Guaifenesin: 600mg twice daily to help loosen mucus.
- Continue Lisinopril 20mg daily.
- Symptom monitoring: Return in one week for follow-up or sooner if symptoms worsen.
- Patient Education: Instruct patient on proper inhaler technique, importance of hydration, and rest. Advise her to avoid irritants like smoke and dust. Reinforce the importance of following up for diagnostic results.
Common Questions Regarding SOAP Notes:
What is a SOAP note, and why is it important?
A SOAP note is a method of documentation used by healthcare professionals to record a patient encounter. It is crucial for effective communication among healthcare providers, ensures continuity of care, facilitates accurate billing, and provides a legal record of the patient's visit. Consistent, accurate, and complete SOAP note writing is a key component of high-quality healthcare delivery.
How do I improve my SOAP note writing skills?
Practice is key! Review examples, utilize templates (while adapting them to each individual patient), and seek feedback from supervisors or colleagues. Focus on clarity, conciseness, and accuracy.
What are some common mistakes to avoid in SOAP note writing?
Common mistakes include illegible handwriting, omitting crucial information, using jargon or abbreviations not understood by everyone involved in the patient's care, and failing to document all relevant assessment findings. Also, avoid vague or subjective language; use precise and measurable terms whenever possible.
This example provides a framework. Remember to tailor your SOAP note to the specific circumstances of each patient encounter. Always prioritize accuracy and completeness in your documentation.
