Medical reference sources, print or online

Question

You’ve read about SOAP notes in the lessons. Creating SOAP notes for an imaginary patient will help you understand and remember the content and organization of these medical records.

Step 1: Find Out What a SOAP Note Looks Like
Search online for terms such as “SOAP notes example” and “SOAP notes template.” If you are interested in a particular branch of medicine, you might search for “physical therapy SOAP notes” or “speech therapy SOAP notes.” (Or you can check medical textbooks instead of going online. Look for “SOAP notes” in each book’s index.) Look at a few examples of these notes. What do they have in common?

Step 2: Create a Template for Your SOAP Notes
In a word processing document, start typing the headings and other information you will need to include. You can make a chart or other graphic organizer, or you can stick with plain text. Don’t worry about making your document look exactly like the models or templates you saw. Just make sure your document is clear and has the four sections in the correct order.

Step 3: Invent a Patient
Fill out your notes with information about an imaginary patient. This person could be in excellent health or could have a rare illness.

Step 4: Review Your Notes
Compare what you have written with the models and templates you saw. Does everything in your SOAP notes make sense? Did you leave out anything?

Submit your SOAP notes to the dropbox.

Answer 1

Step 1: Overview of SOAP Notes

SOAP notes are a structured method for documenting medical information. They are divided into four sections:

• S: Subjective - This section includes the patient's reported symptoms, feelings, and perceptions.
• O: Objective - This includes observable and measurable data from examinations, tests, and observations.
• A: Assessment - This is where the healthcare provider analyzes the subjective and objective information to provide a diagnosis or evaluate progress.
• P: Plan - This outlines the treatment plan, including further tests, medications, patient education, and follow-up appointments.

Step 2: SOAP Note Template

**SOAP Note Template**

**Patient Name:** ______________________  
**Date:** _____________________________  
**DOB:** _____________________________  
**MRN:** ______________________________  

**S: Subjective**  
- Chief Complaint:  
- History of Present Illness:  
- Review of Systems:  
- Medications:  
- Allergies:  

**O: Objective**  
- Vital Signs:  
- Physical Exam Findings:  
- Lab Results:  
- Imaging Results:  

**A: Assessment**  
- Diagnosis:  
- Differential Diagnosis if applicable:  

**P: Plan**  
- Medications:  
- Further Testing:  
- Referrals:  
- Patient Education:  
- Follow-Up Instructions:  

Step 3: Example SOAP Notes

Patient Name: John Doe
Date: October 25, 2023
DOB: January 15, 1980
MRN: 123456

S: Subjective

• Chief Complaint: "I've been feeling fatigued for the past month."
• History of Present Illness: Patient reports persistent fatigue that has been progressively worsening. He describes difficulty concentrating and occasionally has headaches. Denies any significant changes in diet or sleep.
• Review of Systems: No fever, chills, or weight loss. No shortness of breath or chest pain.
• Medications: Currently takes only a multivitamin.
• Allergies: No known drug allergies.

O: Objective

• Vital Signs: BP 120/80, HR 68, R 16, Temp 98.6°F
• Physical Exam Findings: Patient appears well-nourished but fatigued; no palpable lymphadenopathy; unremarkable heart and lung exams.
• Lab Results: CBC pending; LFTs within normal limits.
• Imaging Results: No imaging performed.

A: Assessment

• Diagnosis: Primary fatigue, likely related to lifestyle factors.
• Differential Diagnosis: Sleep disorder, anemia, thyroid dysfunction.

P: Plan

• Medications: Continue multivitamins.
• Further Testing: Order CBC and TSH.
• Referrals: Consider referral to a sleep specialist if the fatigue persists.
• Patient Education: Discuss the importance of sleep hygiene, balanced diet, and regular exercise.
• Follow-Up Instructions: Return in one month for follow-up and review lab results.

Step 4: Review Your Notes

Upon reviewing the SOAP notes, I ensured clarity and coherence. Each section was filled adequately, capturing relevant details and plans for the imaginary patient. The notes follow the standard structure observed in previous templates and examples. Everything contained within the notes aligns with the expectations of professional documentation.

Submission

The SOAP notes for the imaginary patient have been created and are ready for submission to the dropbox.