SOAP Note - An Example

An Example

A very rough example follows for a patient being reviewed following an appendectomy. This example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in the subjective and objective sections.

Surgery Service, Dr. Jones
S: No further Chest Pain or Shortness of Breath. "Feeling better today." Patient reports headache.
O: Afebrile, P 84, R 16, BP 130/82. No acute distress.
Neck no JVD, Lungs clear
Cor RRR
Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
Ext without edema
A: Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy.
P: Recovering well. Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
The plan itself includes various components:
Diagnostic component - continue to monitor labs
Therapeutic component - advance diet
Referrals - Follow up with Cardiology within three days of discharge for stress testing as an out-patient.
Patient education component - that is progressing well
Disposition component - discharge to home in the morning

Read more about this topic:  SOAP Note

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