Sample SOAP Note: Nurse Practitioner
This sample SOAP note demonstrates a standard format. Remember, this is a sample and should not be used in place of proper medical training and clinical judgment. Always adapt the note to reflect the specific patient encounter and your clinical findings. Legal and regulatory requirements vary by location; consult relevant guidelines for your practice.
Patient: Jane Doe, DOB: 01/01/1980
Date: October 26, 2023
Time: 10:00 AM
Subjective (S):
- Chief Complaint (CC): "Persistent cough and shortness of breath for two weeks."
- History of Present Illness (HPI): Patient reports a dry, non-productive cough that began two weeks ago. The cough is worse at night and is accompanied by shortness of breath, particularly with exertion. Denies fever, chills, or chest pain. Reports feeling increasingly fatigued over the past week. No known recent exposures to illness. Patient denies smoking or exposure to environmental irritants.
- Past Medical History (PMH): Hypertension, well-controlled with Lisinopril 20mg daily.
- Past Surgical History (PSH): None.
- Allergies: NKDA (No Known Drug Allergies).
- Medications: Lisinopril 20mg daily.
- Social History (SH): Patient works as a teacher. Reports moderate stress levels. Denies alcohol or illicit drug use.
- Family History (FH): Mother with history of hypertension. Father with history of heart disease.
Objective (O):
- Vital Signs: BP 130/80 mmHg, HR 90 bpm, RR 20 breaths/min, Temp 98.6°F (oral), SpO2 95% on room air.
- Physical Exam: Lungs: clear to auscultation bilaterally. Heart: regular rate and rhythm, no murmurs, rubs, or gallops. HEENT: normal. Skin: warm and dry. No edema.
- Laboratory Data: None ordered at this time.
Assessment (A):
- Likely Diagnosis: Acute Bronchitis. Differential diagnosis includes upper respiratory infection and asthma exacerbation.
- Reasoning: The patient presents with a cough and shortness of breath for two weeks, without fever or significant other symptoms. The physical exam reveals clear lung sounds, suggesting bronchitis rather than pneumonia. Further investigations may be warranted depending on symptom progression.
Plan (P):
- Diagnostic Studies: Chest x-ray if symptoms worsen or fail to improve. Consider pulmonary function tests (PFTs) if significant wheezing develops.
- Treatment: Recommend increased fluid intake, rest, and over-the-counter cough suppressant (e.g., dextromethorphan). Instruct patient to monitor symptoms and return if they worsen or if new symptoms develop. Follow-up appointment scheduled in one week.
- Patient Education: Educate patient on the importance of rest, hydration, and symptom monitoring. Advised on appropriate use of over-the-counter medications. Discussed potential complications and when to seek immediate medical attention.
Note: This is a sample SOAP note and may not be applicable to all clinical situations. Always use your clinical judgment and adhere to relevant legal and regulatory guidelines. This note should not be used as a substitute for proper medical training and professional consultation.
