Description
SOAP Notes 2
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
GDownload Graduate SOAP NOTE TEMPLATE.docx
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
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Explanation & Answer
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SOAP Note
Name of the student
Institutional affiliation
Date of submission
Copyright © MVJ 2018
SOAP Note
Encounter date: 15/09/2021
Patient Initials: J.K Gender: M/F/Transgender J.K Age: 52 years. Race: Latin American Ethnicity: Latin
Reason for Seeking Health Care: "I feel like an elephant is thumping in my chest. My feet and abdomen
have swollen, and I feel tired after walking over a short distance."
HPI: The above chief complaints started two months ago. The patient started experiencing chest
pains followed by shortness of breath that comes with palpitations. The chest pains are more
severe with activities such as walking and jogging. Chest pains are relieved with rest.
Allergies(Drug/Food/Latex/Environmental/Herbal): None.
Current perception of health: fair
Past Medical History
• Major/Chronic Illnesses: no history of chronic illness
• Trauma/Injury: head injury in 2016 after a road traffic accident
• Hospitalizations: admitted once in 2016 following a road traffic accident
Past Surgical History: craniotomy to drain the hematoma in 2016.
Medications: ceftriaxone drug for prophylaxis purposes. Furosemide to prevent water retention.
Phenytoin to prevent seizures. Magnesium sulfate prevents the increased stimulation of neurons.
Family History: Firstborn in a family of three children. Both siblings are alive and well. Mother
is alive and well, while the father died of hypertensive emergency in 2002. He is married with
one child. He lives with his wife and child.
Copyright © MVJ 2018
Social history:
Lives: Single-family House/Condo/ with stairs: Single-family house Marital Status:
married Employment Status: employed Current/Previous occupation type: teacher.
Exposure to: Smoke: Ye...