[2024] Episodic SOAP Note Template Example

Written By: Dan Palmer, RN

Episodic SOAP Note Template Example

Episodic SOAP Note Template Example

Episodic Focused SOAP Note Template

Patient Information:

TMF, 23, AAF

S.

CC “I noticed that I have an odor down there”

HPI: Patient presents to office for a follow up from her appt on 02/6/23 well woman gynecological visit in which her pap smear resulted: ABNORMAL ASCUS, HPV + but neg. for 16,18,45. Patient is scheduled on today’s date for a colposcopy. Patient also reports that for the past week she has been having a “fishy” vaginal odor. Denies discharge, pain or itching.

Current Medications:

EluRyng 0.12 mg-0.015 mg/24 hr vaginal ring

INSERT 1 RING VAGINALLY AS DIRECTED. Exchange ring every 4 weeks.

Ibuprofen 800mg Tablet

Use prn pain q 8 hours. Take with food.

azithromycin 500 mg tablet

TAKE 2 TABLETS BY MOUTH EVERY DAY FOR 1 DAY

Allergies: Patient denies allergies to food or medicine

PMHx: .

  •  Atypical squamous cells of undetermined significance – Onset: 02/10/2020
  • Vaginitis – Onset: 08/17/2022 – ureaplasma and AV organisms
  • COVID-19 – Onset: 03/17/2020
  • HPV – Human papillomavirus test positive – Onset: 03/23/2018 – neg.16,18,45
  • Genital herpes simplex – Onset: 03/18/2018
  • Chlamydia –Onset: 03/18/2018

Soc & Substance Hx: Are you blind or do you have difficulty seeing?: No

Are you deaf or do you have serious difficulty hearing? No

Do you have difficulty concentrating, remembering or making decisions? No

Do you have difficulty walking or climbing stairs? No

Do you have difficulty dressing or bathing? No

Do you have difficulty doing errands alone? No

Diet and Exercise

What type of diet are you following? Regular

What is your exercise level? None

Other

Education: 12

History of inconsistent/no condom use: Yes

Marital status: Single

General stress level: Low

Education and Occupation

What is the highest grade or level of school you have completed or the highest degree you have received? High school graduate

Are you currently employed? Yes

What is your occupation? server/ leasing consultant

Substance Use

Do you or have you ever smoked tobacco? Never smoker

How much tobacco do you smoke? None

How many years have you smoked tobacco? NA

Do you or have you ever used any other forms of tobacco or nicotine? No

Do you or have you ever used e-cigarettes or vape? Never used electronic cigarettes

Do you or have you ever used smokeless tobacco? Never used smokeless tobacco

What was the date of your most recent tobacco screening? 02/06/2023

What is your level of alcohol consumption? Moderate (Notes: 1-3 times a week couple of drinks)

Do you use any illicit or recreational drugs? Yes

Which illicit or recreational drugs have you used? Cannabis

What is your level of caffeine consumption? Occasional (Notes: 1 8-12oz coffee daily)

Advance Directive

Do you have an advance directive? No

Is blood transfusion acceptable in an emergency? Yes

Marriage and Sexuality

What is your relationship status? Single

Are you sexually active? Yes

Public Health and Travel

Have you been to an area known to be high risk for COVID-19? No

In the 14 days before symptom onset, have you had close contact with a laboratory-confirmed COVID-19 while that case was ill? No

In the 14 days before symptom onset, have you had close contact with a person who is under investigation for COVID-19 while that person was ill? No

Lifestyle

Do you feel stressed (tense, restless, nervous, or anxious, or unable to sleep at night)? Not at all

Do you use your seat belt or car seat routinely? Yes

Home and Environment

Do you have smoke and carbon monoxide detectors in your home? Yes

Are there any guns present in your home? No

Do you use sunscreen routinely? Yes

Gender Identity and LGBTQ Identity

Gender identity: Identifies as Female

Assigned sex at birth: Female

Pronouns: she/her

Sexual orientation: Straight or heterosexual

Fam Hx:

No children

Father- No medical concerns or disabilities

Mother-No medical concerns or disabilities

Maternal Grandmother- DMII

Maternal Grandfather- Medical hx unk

Paternal Grandmother- Medical hx unk

Paternal Grandfather- Medical hx unk

Surgical Hx: Tonsillectomy (stated it was more than 15 years ago)

Mental Hx:  No reports of depression, anxiety or SI

Violence Hx: States that neighborhood is safe, no guns in the home and feels safe in her relationship

Reproductive Hx:

Duration of Flow (days): 5.
LMP: Definite (Notes: 01/07/23-01/12/23).
Frequency of Cycle (Q days): 28.
Menses Monthly: N.
Flow: Moderate (Notes: uses regular pads changes 6 in 24 hours).
Age at First Child: 0.
Age at Menarche: 12.
Current Birth Control Method: Condoms (Notes: removed vaginal ring to give her body a break).
Abnormal Pap: Y (Notes: ASCUS HPV not typed).
Colonoscopy: (Notes: none).
Date of Last Pap Smear: 02/06/2023 (Notes: HPV + 16,18,45-).
Hormone Replacement Therapy: N.
Most Recent Bone Density: (Notes: none).
Most Recent Mammogram: (Notes: none).
Sexual Problems?: N.
Sexually Active?: Yes (Notes: last active date 02/15/2023).
STIs/STDs: Yes (Notes: herpes, had chlamydia years ago. HAs HPV).

Total (1) Full (0) Pre (0) AB.1 (0) AB.S (1) Ectopic (0) Living (0) Multiple (0)

Spontaneous abortion at 10 weeks age 15

ROS:

GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching. Breast-lumps, pain, discharge

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: Denies burning on urination, frequency and urgency. Reports vaginal odor

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Constitiutional: Patient A&O x4. No deviations in gait. Clear and coherent speech. Answers questions appropriately. Makes good eye contact and is cooperative during assessment and exam. Dressed appropriately for weather and setting.

VS

Ht:         5 ft 3 in

Wt:        179 lbs

BMI:      31.7

BP:         118/80 sitting R arm

T:           98.5 F° oral

Cardiovascular: Normal rate and rhythm, No edema, No jugular vein distention

Respiratory: No SOB, Equal rise and fall of chest wall, cap refill <3cc

Genitourinary: vaginal odor present,

Diagnosis:

  1. A. Abnormal vaginal odor

VIKTOR culture-probiotic

N89.8: Other specified noninflammatory disorders of vagina

  1. Cervicovaginal cytology: Low grade squamous intraepithelial lesion

R87.612: Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)

  • PATHOLOGY REPORT-500918-P –

Note to Lab:

All pap done at LABCORPS,
2.6.23 ASCUS, HPV+ (not16,18,45)
11.24.21 HPV+ (neg., 16,18,45)
5.7.21 LGSIL QUEST labs
5.4.20 ASCUS, HPV
3.25.19 Normal
3.15.18 ASCUS. HPV+ neg. 16,18,45

  1. Contraception care management

Z30.9: Encounter for contraceptive management, unspecified

  1. Postoperative pain

G89.18: Other acute post procedural pain

  1. Atypical squamous cells of undetermined significance on cervical Papanicolaou smear

R87.610: Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)

Procedure Documentation:

Colposcopy:

HPV+ (not 16,18,45) ASCUS X 2
Colposcopy procedure fully reviewed. Patient questions regarding procedure and diagnosis answered. Consent was signed. A speculum was placed into the vagina. The cervix and vagina were painted with acetic acid solution. The entire T zone was visualized with irregular borders.
Colposcopy revealed the following (see attached diagram):

Possible metaplasia or CIN 1-2
An ECC was not performed.
Silver nitrate stick & pressure was applied for hemostasis.
Patient tolerated procedure well.

Ibuprofen 800 mg. given with hot tea post

Episodic SOAP Note Template Example

Episodic Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

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. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Conduct a cultural self-assessment. In order to understand culture and cultural diversity, it is important that you understand your own culture and heritage

What is an episodic soap note?

What is an episodic soap note? An episodic soap note is a documentation format used in healthcare settings, particularly by healthcare providers such as doctors, nurses, and other medical professionals. The episodic nature of the soap note means that it focuses on a specific episode or encounter with the patient.

Comprehensive vs episodic soap note

Comprehensive SOAP note provides a more extensive and detailed overview of the patient’s health, incorporating historical information and long-term considerations. On the other hand, episodic SOAP note is more narrowly focused, capturing the specifics of a single healthcare encounter and tailoring the documentation to the immediate needs of that episode.

Episodic visit heent focused note

An episodic HEENT-focused SOAP note for a healthcare visit would be structured as follows:

  1. Subjective (S):
    • Chief Complaint: A concise statement capturing the main reason for the patient’s visit, related to the Head, Eyes, Ears, Nose, and Throat (HEENT) system.
    • History of Present Illness (HPI): Detailed information about the current symptoms, their onset, duration, severity, and any associated factors. Focus on HEENT-related aspects.
  2. Objective (O):
    • General: Note the patient’s general appearance and demeanor.
    • Head: Document any abnormalities, tenderness, or masses.
    • Eyes: Record visual acuity, eye movements, pupillary response, and any signs of redness or discharge.
    • Ears: Include findings from otoscopic examination, checking for earwax, inflammation, or other abnormalities.
    • Nose: Document any nasal congestion, discharge, or abnormalities in the nasal cavity.
    • Throat: Mention any sore throat, difficulty swallowing, or other relevant throat symptoms. Include findings from examining the tonsils and pharynx.
  3. Assessment (A):
    • Summarize the findings from the subjective and objective sections.
    • Provide a brief analysis or impression related to the patient’s HEENT symptoms.
  4. Plan (P):
    • Detail the plan for further evaluation or treatment:
      • Diagnostic tests, if needed (e.g., imaging, labs).
      • Prescribed medications or therapies.
      • Referrals to specialists, if necessary.
      • Follow-up instructions and timeframe.

Headache soap note

Below is a sample SOAP note for a patient presenting with a chief complaint of headache:

  1. Subjective (S):
    • Chief Complaint: The patient reports a headache.
    • History of Present Illness (HPI): The headache began [insert duration] ago and is described as [insert characteristics – throbbing, sharp, dull]. The patient rates the pain as [insert severity on a scale of 1 to 10]. Associated symptoms include [insert associated symptoms – nausea, sensitivity to light, etc.]. There is no history of recent head trauma.
  2. Objective (O):
    • General: The patient appears [insert general appearance – well, unwell, in distress].
    • Vital Signs: Blood pressure, heart rate, respiratory rate, and temperature within normal limits.
    • Head: No visible signs of trauma or abnormalities.
    • Neurological Exam: Cranial nerves intact. No focal neurological deficits.
    • Other Relevant Exams: [Include any additional exams relevant to the patient’s complaint.]
  3. Assessment (A):
    • Primary Diagnosis: Tension-type headache.
    • Differential Diagnosis: Migraine, sinus headache.
    • Contributing Factors: [Consider stress, lack of sleep, etc.]
  4. Plan (P):
    • Treatment: Advise over-the-counter pain relievers (e.g., acetaminophen, ibuprofen) as needed.
    • Lifestyle Recommendations: Encourage stress reduction techniques, adequate hydration, and regular sleep.
    • Follow-up: Schedule a follow-up visit if symptoms persist or worsen. Consider imaging or further evaluation if red flags or atypical features emerge.
    • Education: Provide information on signs and symptoms that should prompt immediate medical attention.

Musculoskeletal SOAP Note

Here’s a sample SOAP note for a patient presenting with a chief complaint related to the musculoskeletal system, such as joint pain or a specific musculoskeletal issue:

  1. Subjective (S):
    • Chief Complaint: The patient reports [insert specific musculoskeletal complaint, e.g., knee pain].
    • History of Present Illness (HPI): The pain started [insert duration] ago and is described as [insert characteristics – sharp, aching, constant]. It is exacerbated by [insert aggravating factors – movement, specific activities]. Any recent trauma or injury related to the complaint should be documented. Include the impact on daily activities.
  2. Objective (O):
    • General: The patient appears [insert general appearance – comfortable, in distress].
    • Vital Signs: Within normal limits.
    • Musculoskeletal Exam:
      • Inspection: Note any swelling, redness, or deformities.
      • Palpation: Identify areas of tenderness, warmth, or swelling.
      • Range of Motion (ROM): Assess the range of motion of the affected joint.
      • Strength Testing: Evaluate muscle strength related to the complaint.
      • Neurovascular Exam: Assess circulation, sensation, and motor function.
  3. Assessment (A):
    • Primary Diagnosis: [e.g., Osteoarthritis of the knee, Rotator cuff injury].
    • Differential Diagnosis: [Consider other possible causes, such as ligament strain, bursitis].
    • Contributing Factors: [e.g., history of trauma, repetitive use].
  4. Plan (P):
    • Treatment: Prescribe pain relief (e.g., NSAIDs), physical therapy, or other interventions as appropriate.
    • Referrals: Consider referrals to specialists (e.g., orthopedic surgeon, physical therapist) if needed.
    • Imaging: Order imaging studies (e.g., X-rays, MRI) if necessary for further evaluation.
    • Follow-up: Schedule a follow-up to monitor progress or adjust the treatment plan as needed.
    • Patient Education: Provide information on self-care, activity modifications, and signs that warrant immediate medical attention.
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