SOAP NOTE SUBJECTIVE DATA:
Below is a step-by-step guide on how to write the soap note subjective data, including three examples of the soap note subjective section for NPs and aspiring RNs. In the soap note subjective data section, we have the Chief Complaint, History of present illness ( You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:), medications, allergies, Past Medication History, Past Surgical History (PSH), Sexual/Reproductive History, Personal/Social History, Immunization History, Significant Family History, Lifestyle, and Review of Systems.
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
- O = onset of symptom (acute/gradual)
- L= location
- D= duration (recent/chronic)
- C= character
- A= associated symptoms/aggravating factors
- R= relieving factors
- T= treatments previously tried – response? Why discontinued?
- S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. (You can use the patients words and quote them) for instance
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
SOAP NOT SUBJECTIVE EXAMPLE 1
Chief Complaint (CC): Painful blistering rash limited on a stripe-like area of the arm
History of Present Illness (HPI): ABC is a 57-year-old female of Cuban Hispanic origin. The patient presented at the clinic with complaint of a Painful rash limited on a stripe-like area of the arm. She believes she has had it for the last 4 days. She complains of pain and discomfort when using the right arm to do any home chores. She has had shingles in twice in the past 5 years and notes that it feels the same as in the past. She has been taking 2 tablets of Tylenol every 6 hours to manage the pain. ABC rates her pain as an 8 out of 10 on the pain scale 0-10.
- Aspirin 81 mg daily
- Lipitor 20 mg daily
- Hydrochlorothiazide 50 mg daily
- Atenolol 100 mg daily
- Diovan 80 mg daily,
Allergies: Has no known drug allergy, no seasonal or environmental allergies
Past Medical History (PMH):
- Hypertension for two years
- Hyperlipidemia controlled by Simistatin
- chronic obstructive pulmonary disease- quiet
- mild pulmonary hypertension
Past Surgical History (PSH):
Minor surgery to remove atypical moles for melanocytic nevi from her left-hand fingers 3 years ago (Colyar, 2015)
Sexual/Reproductive History: If applicable,
Adopted light exercises and is on a diet for the last 4 months
Flu- Has not received for this flu season.
Tetanus/Pertussis- Unsure of her last vaccination.
Significant Family History: Family history of Hypertension, Obesity and diabetes
Lifestyle: Lives with husband and youngest daughter. Close family lives nearby, has a support system. She owns her home, and receives pension. Financially independent,
Has taken up walking and jogging for the last 6 months, slight changes in diet, support from family members play a key role.
Review of Systems:
General: + fatigue and fevers for 4 days, slight weight loss, poor sleep since illness started.
CARDIOVASCULAR/PERIPHERAL VASCULAR: SOB, Fatigue w/e exertion, Date of ECG/ Cardiac work up is 8 months ago.
Breasts: No history of abnormal mammograms, no breast changes, no history of rashes, or lesions in the breast area
GI: No abdominal pain, no nausea or vomiting, no diarrhea, no constipation, no melena, no hematochezia, no hemorrhoids and no indigestion.
GU: Slight stress Incontinence, No history of STD’s or HPV, heterosexual, and sexually active
MS: No myalgia, no arthritis, She complains of slight weakness
Psych: no history of anxiety or depression, no suicidal or homicidal history
Neuro: no headaches or imbalance. No change in memory or thinking patterns; no twitches or abnormal movements, No falls or seizure history.
HEME: rashes on right arm, no radiation of rash at this time, no itching, no acne, history of moles on left fingers, no hair loss, no history of skin cancer. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endo: No endocrine symptoms or hormone therapies
Allergic/ Immunologic: Has no known immune deficiencies, Last HIV test was 3 years ago.
SOAP NOTE SUBJECTIVE EXAMPLE 2
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
- Lisinopril 10mg daily
- Combivent 2 puffs every 6 hours as needed
- Serovent daily
- Salmeterol daily
- Over the counter Ibuprofen 200mg -2 PO as needed
- Over the counter Benefiber
- Flonase 1 spray each night as needed for allergic rhinitis symptoms
Sulfa drugs – rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
5.) Allergic rhinitis
Past Surgical History (PSH):
- Cholecystectomy 1994
- Total abdominal hysterectomy (TAH) 1998
Non-menstrating – TAH 1998
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.
She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.
Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.
GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.
GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.
MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.
Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.
Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.
Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: no endocrine symptoms or hormone therapies.
Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.
SOAP NOTE SUBJECTIVE EXAMPLE 3
Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally