This sample SOAP note demonstrates a format commonly used by Nurse Practitioners (NPs). Remember that specific requirements may vary depending on the healthcare setting, electronic health record (EHR) system, and state regulations. This is for illustrative purposes only and should not be used as a template for actual patient care. Always adhere to your institution's guidelines and best practices.
Patient: Jane Doe, DOB: 01/01/1980 Date: October 26, 2023 Medical Record Number: 1234567 Provider: [Your Name], NP
S: Subjective
Chief Complaint: Patient presents with complaints of persistent cough for three weeks, accompanied by fatigue and occasional shortness of breath.
History of Present Illness (HPI): The patient reports a cough that began three weeks ago. Initially, it was dry, but now it produces clear sputum. She denies fever, chills, or night sweats. She reports increased fatigue over the past two weeks, impacting her ability to perform daily activities. She notes shortness of breath with exertion, such as climbing stairs. She denies chest pain. She has been using over-the-counter cough suppressants with minimal relief. She denies recent travel or contact with anyone who is sick.
Past Medical History (PMH): Asthma (well-controlled with albuterol inhaler as needed), seasonal allergies.
Past Surgical History (PSH): None.
Family History (FH): Father with hypertension and hyperlipidemia; Mother with history of breast cancer.
Social History (SH): Patient is a non-smoker. She drinks alcohol occasionally (1-2 glasses of wine per week). She denies illicit drug use. She works as a teacher and reports moderate stress levels.
Medications: Albuterol inhaler (PRN). Over-the-counter cough suppressant (occasional use).
Allergies: NKDA (no known drug allergies).
O: Objective
Vital Signs: Temperature: 98.6°F (oral), Heart Rate: 80 bpm, Respiratory Rate: 18 breaths/min, Blood Pressure: 120/80 mmHg, Oxygen Saturation: 99% on room air.
Physical Exam: General appearance: Well-nourished, alert, and oriented. Lungs: Clear to auscultation bilaterally, except for occasional scattered rhonchi in the right lower lobe. Heart: Regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen: Soft, non-tender, non-distended.
Diagnostic Tests: None ordered at this time.
A: Assessment
Acute Bronchitis: Given the patient's history of cough with sputum production, fatigue, and shortness of breath, a diagnosis of acute bronchitis is suspected.
P: Plan
Further Investigations: Given the persistent nature of her symptoms, we will monitor her progress. Chest X-ray may be considered if symptoms worsen or fail to improve.
Treatment: Encourage increased fluid intake, rest, and avoidance of irritants such as smoke and dust. Continue use of albuterol inhaler as needed for any wheezing. Prescribing a course of antibiotics is not recommended routinely for acute bronchitis unless there are signs of a bacterial infection. Recommend trying an over-the-counter expectorant to help thin the mucus. Follow-up appointment scheduled in one week to assess symptom improvement.
Patient Education: Educated the patient on the expected course of acute bronchitis, the importance of rest and hydration, and when to seek further medical attention (e.g., worsening shortness of breath, fever, chest pain).
Referral: None needed at this time.
Note: This is a sample SOAP note. Always ensure that your SOAP note accurately reflects the patient's condition, your assessment, and your plan of care. This information is not a substitute for professional medical advice. Always consult with a qualified healthcare provider for any health concerns or before making any decisions related to your health or treatment.
