soap note 2

Instructions:

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.

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

Click here to access and download the SOAP Note Template

Download Click here to access and download the SOAP Note Template

Submission Instructions:

• Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
• You must use the template provided. 

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:

SOAP NOTE TEMPLATE Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 1 to >0.8 pts
Begins with patient
initials, age, race,
ethnicity and
gender (5
demographics)

0.8 to >0.25 pts
Begins with 4 of
the 5 patient
demographics
(patient initials,
age, race,
ethnicity and
gender)

0.25 to
>0.0 pts
Begins with 3
or less patient
demographics
(patient
initials, age,
race, ethnicity
and gender)

0 pts
Missing
criteria
and/or
submission
.

1
point

Chief
Complaint
(Reason for
seeking health
care)

4 to >3.0 pts
Includes a direct
quote from patient
about presenting
problem

3 to >2.0 pts
Includes a direct
quote from
patient and
other unrelated
information

2 to >0.0 pts
Includes
information
but
information is
NOT a direct
quote

0 pts
Missing
criteria
and/or
submission
.

4
points

History of the
Present
Illness (HPI)

5 to >3.0 pts
Includes the
presenting problem
and the 8
dimensions of the
problem (OLD
CARTS – Onset,
Location, Duration,
Character,
Aggravating
factors, Relieving
factors, Timing and
Severity)

3 to >2.0 pts
Includes the
presenting
problem and 7
of the 8
dimensions of
the problem
(OLD CARTS –
Onset, Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors, Timing
and Severity)

2 to >0.0 pts
Includes the
presenting
problem and 6
of the 8
dimensions of
the problem
(OLD CARTS –
Onset,
Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors,
Timing and
Severity)

0 pts
Missing
criteria
and/or
submission
.

5
points

Allergies 2 to >1.5 pts
Includes NKA
(including = Drug,
Environmental,
Food, Herbal,
and/or Latex or if
allergies are
present (reports for
each severity of
allergy AND
description of
allergy)

1.5 to >1.0 pts
If allergies are
present,
students lists
type Drug,
environmental
factor, herbal,
food, latex name
and includes
severity of
allergy OR
description of
allergy

1 to >0.0 pts
If allergies are
present,
students lists
only the type
of allergy
name

0 pts
Missing
criteria
and/or
submission
.

2
points

Review of
Systems
(ROS)

15 to >8.0 pts
Includes a
minimum of 3
assessments for
each body system
and assesses at
least 9 body
systems directed to
chief complaint
AND uses the
words “admits” and
“denies”

8 to >3.0 pts
Includes 3 or
fewer
assessments for
each body
system and
assesses 5-8
body systems
directed to chief
complaint AND
uses the words
“admits” and
“denies”

3 to >0.0 pts
Includes 3 or
fewer
assessments
for each body
system and
assesses less
than 5 body
systems
directed to
chief
complaint OR
student does
not use the
words
“admits” and
“denies”

0 pts
Missing
criteria
and/or
submission
.

15
points

Vital Signs 2 to >1.5 pts
Includes all 8 vital
signs, (BP (with
patient position),
HR, RR,
temperature (with
Fahrenheit or
Celsius and route
of temperature
collection), weight,
height, BMI (or
percentiles for
pediatric
population) and
pain.)

1.5 to >1.0 pts
Includes 7 vital
signs, (BP (with
patient
position), HR,
RR, temperature
(with Fahrenheit
or Celsius and
route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population) and
pain.)

1 to >0.0 pts
Includes 6 or
less vital
signs, (BP
(with patient
position), HR,
RR,
temperature
(with F or C
and route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population)
and pain.)

0 pts
Missing
criteria
and/or
submission
.

2
points

Labs 2 to >1.5 pts
Includes a list of
the labs reviewed at
the visit, values of
lab results and
highlights
abnormal values
OR acknowledges
no labs/diagnostic
tests were
reviewed.

1.5 to >1.0 pts
Includes a list of
the labs
reviewed at the
visit, values of
lab results but
does not
highlight
abnormal
values.

1 to >0.0 pts
Includes a list
of the labs
reviewed at
the visit but
does not
include the
values of lab
results or
highlight
abnormal
values.

0 pts
Missing
criteria
and/or
submission
.

2
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

2 to >1.0 pts
Includes a list of
all of the patient
reported
medications and
the medical
diagnosis for
the medication
(including 3 of

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past Medical
History

3 to >2.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations),
for each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active
or current

2 to >1.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations)
, for each
medical
diagnosis, either
year of
diagnosis OR
whether the
diagnosis is
active or current

1 to >0.0 pts
Includes each
medical
diagnosis but
does not
include year of
diagnosis or
whether the
diagnosis is
active or
current

0 pts
Missing
criteria
and/or
submission
.

3
points

Past Surgical
History

3 to >2.0 pts
Includes, for each
surgical procedure,
the year of
procedure and the
indication for the
procedure

2 to >1.0 pts
Includes, for
each surgical
procedure, the
year of
procedure OR
indication of the
procedure

1 to >0.0 pts
Includes, for
each surgical
procedure but
not the year of
procedure or
indication of
the procedure

0 pts
Missing
criteria
and/or
submission
.

3
points

Family History 3 to >2.0 pts
Includes an
assessment of at
least 4 family
members
regarding, at a
minimum, genetic
disorders, diabetes,
heart disease and
cancer.

2 to >1.0 pts
Includes an
assessment of
at least 3 family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

1 to >0.0 pts
Includes an
assessment of
at least 2
family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

0 pts
Missing
criteria
and/or
submission
.

3
points

Social History 3 to >2.0 pts
Includes all of the
required following:
tobacco use, drug
use, alcohol use,
marital status,
employment status,
current/previous
occupation, sexual
orientation,
sexually active,
contraceptive use,
and living situation.

2 to >1.0 pts
Includes 10 of
the 11 required
following:
tobacco use,
drug use,
alcohol use,
marital status,
employment
status,
current/previous
occupation,
sexual
orientation,
sexually active,
contraceptive

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
Maintenance /
Screenings

3 to >2.0 pts
Includes a detailed
assessment of
immunization
status and other
health maintenance
needs such as age-
appropriate
screenings and
preventive
measures Includes
an assessment of
at least 5 screening
tests

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 pts
Includes a detailed
pharmacologic
treatment plan for
each of the
diagnoses listed
under
“assessment”. The
plan includes ALL
of the required
following: drug
name, dose, route,
frequency, duration
and cost as well as
education related to
pharmacologic
agent. If the
diagnosis is a
chronic problem,
student includes
instructions on
currently
prescribed
medications as
above.

3 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
following 7: the
drug name,
dose, route,
frequency,
duration and
cost as well as
education
related to
pharmacologic
agent. If the
diagnosis is a
chronic
problem,
student includes
instructions on
currently
prescribed
medications as
above.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 pts
Includes at least 3
strategies to
promote and
develop skills for
managing their
illness and at least
3 self-management
methods on how to
incorporate healthy
behaviors into their
lives.

2 to >1.0 pts
Includes at least
2 strategies to
promote and
develop skills
for managing
their illness and
at least 2 self-
management
methods on how
to incorporate
healthy
behaviors into
their lives.

1 to >0.0 pts
Includes at
least 1
strategies to
promote and
develop skills
for managing
their illness
and at least 1
self-
management
methods on
how to
incorporate

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 pts
Includes at least 3
primary prevention
strategies (related
to age/condition
(i.e. immunizations,
pediatric and pre-
natal milestone
anticipatory
guidance)) and at
least 2 secondary
prevention
strategies (related
to age/condition
(i.e. screening))

2 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
Includes at
least 1 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations
, pediatric and
pre-natal
milestone
anticipatory
guidance))
and at least 1
secondary
prevention
strategies
(related to
age/condition
(i.e.
screening))

0 pts
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100

SOAP
Demographics	Patient (A.R.) is a 5-year-old white Hispanic male. Encounter Date: 03/37/2025
Chief Complaint (Reason for seeking health care)	Per mother “My son has been coughing and has had a runny nose for three days.”
History of Present Illness (HPI)	As per mother’s report, the patient’s coughing and runny nose has an onset of 3 days ago. The present illness is located within the upper respiratory tract. The duration of the patient’s symptoms is persistent. Symptoms include a dry cough with nasal congestion and rhinorrhea. Symptoms are aggravated at night and can be relieved with warm fluids and honey that reportedly help a little bit. The timing of the symptoms is intermittent throughout the past three days but consistent overnight. Severity of the symptoms are mild to moderate, but mother reports that her son has thankfully not had any difficulty breathing.
Allergies	As per the mother the patient has no known drug, environmental, food, herbal, and/or latex allergies.
Review of Systems (ROS)	General: Mother admits a low-grade fever (100.2°F) noted yesterday; no chills or night sweats. HEENT: Mother admits the patient has congested nasal passages, clear rhinorrhea, dry throat, and mild ear discomfort. Neck: Mother denies swelling or stiffness of the neck. Lungs: Mother admits occasional dry cough, no wheezing or shortness of breath. Cardio: Mother denies palpitations or chest pain. Breast: Mother denies any breast tissue abnormalities with the patient. GI: Mother denies nausea, vomiting, diarrhea, or constipation. M/F genital: Mother denies any perineal abnormalities. GU: Mother denies dysuria or frequency changes. Neuro: Mother denies headaches, dizziness, or altered mental status. Musculo: Mother denies joint or muscle pain. Activity: Mother admits patient has slightly decreased energy level due to illness. Psychosocial: Mother admits patient is well-adjusted, no behavioral concerns. Derm: Mother denies any rashes or skin changes. Nutrition: Mother admits the patient’s appetite has slightly decreased. Sleep/Rest: Mother admits the patient is restless at night due to nasal congestion. LMP: N/A STI Hx: N/A
Vital Signs	BP: 98/62 mmHg in a sitting position HR: 91 bpm RR: 23 breaths/min Temp: 99.8°F axillary SpO2: 98% on room air Weight: 21.2kg Height: 113cm CDC percentile 79.4% Pain: 0 using the FACES scale
Labs	None reviewed at this time; clinical diagnosis based on symptoms.
Medications	Acetaminophen 160 mg oral solution every 4-6 hours as needed PRN for fever. Ocean Nasal Spray sodium chloride nasal spray, 1 spray(s), nasal, as needed PRN for nasal congestion
Past Medical History	No significant major/chronic medical history No history of asthma or respiratory conditions No history of traumas or hospitalizations
Past Surgical History	No past surgical history
Family History	Mother: Endometriosis Father: Hypertension Older brother: Hypothyroidism Maternal grandfather: Type II diabetes
Social History	Patient lives in a single-family home with stairs, with his mother, father, and older brother. Current living situation does not expose the patient to tobacco use and/or smoke, drug use, or alcohol use. Currently attends kindergarten in a public elementary school. Work status: N/A. Sexual orientation: N/A. Sexually active: N/A. Contraceptive use: N/A.
Health Maintenance/ Screenings	Comprehensive physical exam Routine visual screening Routine auditory screening Height and weight for growth chart Up to date on vaccinations, including the flu vaccine.
Physical Examination	General: Well-nourished, alert, interactive HEENT: Head normocephalic, pupils 3mm regular and reactive, no auditory issues, mild nasal congestion, clear rhinorrhea, erythematous pharynx, no exudates, tympanic membranes clear. Neck: No lymphadenopathy, no stiffness or lumps noted. Lungs: Clear to auscultation bilaterally, no wheezing or crackles, chest rise is equal bilaterally Breast: N/A due to lack of breast tissue. Cardio: Regular rate and rhythm, no murmurs, rubs, or gallops. GI: Soft, symmetric non-tender abdomen, normoactive bowel sounds M/F Genital: not examined. GU: unremarkable Neuro: Alert and oriented, no focal deficits, cranial nerves intact Musculo: Normal range of motion, no joint swelling Psychosocial: appropriate mood given feeling slightly uncomfortable due to congestion. Derm: No rashes or lesions noted, no cuts, growths, or irregular moles.
Diagnosis	Acute viral upper respiratory infection (URI)
Differential Diagnosis	Allergic rhinitis Early sinusitis Strep pharyngitis (less likely due to lack of exudates and high fever)
ICD 10 Coding	J06.9 – Acute upper respiratory infection, unspecified
Pharmacologic treatment plan	Acetaminophen 160 mg / 5 mL oral suspension, 5mL by mouth every 4-6 hours as needed for fever. Average cost is $14. Educate parent on importance of not exceeding daily dose limit (Thibault et al., 2023). Ocean Nasal Spray – sodium chloride nasal spray, 1 spray(s), nasal, as needed PRN for nasal congestion. Average cost is $8. Educate parent to try not to use the spray for more than 3 days in a row as rebound rhinitis can occur (Štanfel et al., 2022).
Diagnostic/Lab Testing	Respiratory Pathogen Panel (RPP): negative result.
Education	Strategies to manage illness: 1) Educate the parent on the importance of rest and sleep for the patient, emphasizing how this can impact the recovery process. Encourage frequent naps to allow time for the body to heal. 2) Provide education on proper hygiene and etiquette while the patient is sick, emphasizing proper sneezing technique as well as the importance of handwashing. 3)Familiarize the parent with symptoms to look out for that may indicate a sign of illness, such as a cough, sore throat, or fever. Encourage the parent to communicate if symptoms worsen or new ones appear (Smith et al., 2023). Self-management methods on healthy behaviors: 1) Emphasize importance of keeping the patient hydrated with clear liquids and warm broths. Nutrient dense meals will help support and boost the immune system. 2) Reinforce regular handwashing after coughing, sneezing, or touching the face with soap and water. 3) Educate the parent on gradually introducing physical activity back into the child’s routine once the child is feeling better.
Anticipatory Guidance	Primary prevention: Hand hygiene, age-appropriate education on how to sneeze, cover their mouth, and use tissues. Review immunizations and ensure patient stays on track with required vaccines for their age, including annual flu vaccine. Advocate for a well-balanced diet that can support a healthy immune system. Secondary prevention: Inform mother to monitor for signs of complications and expect symptoms to resolve within 7-10 days, if this does not occur further medical evaluation is necessary (Smith et al., 2023) Reinforce the need for annual visual and auditory screenings for the up-coming visit to keep track of the child’s development.
Follow up plan	Re-evaluation in 1 week if symptoms persist or worsen. Immediate follow-up if fever >100.4°F for more than 3 days or signs of respiratory distress develop (Geppe et al., 2023)

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: A.R. Age 5 Date: 03/27/2025 RX Acetaminophen 160 mg/5 mL oral suspension SIG: Take 5 mL by mouth every 4-6 hours as needed for fever. Dispense: 120 mL Refill: no No Substitution Signature:

References

Geppe, N. A., Zaplatnikov, A. L., Kondyurina, E. G., Chepurnaya, M. M., & Kolosova, N. G. (2023). The Common Cold and Influenza in Children: To Treat or Not to Treat?. 
Microorganisms, 
11(4), 858.

Smith, A., Kardos, P., Pfaar, O., Randerath, W., Estrada Riolobos, G., Braido, F., & Sadofsky, L. (2023). The treatment of mild upper respiratory tract infections – a position paper with recommendations for best practice.
Drugs in Context,
12, 1–15. https://doi.org/10.7573/dic.2023-4-2

Štanfel, D., Kalogjera, L., Ryazantsev, S. V., Hlača, K., Radtsig, E. Y., Teimuraz, R., & Hrabač, P. (2022). The role of seawater and saline solutions in treatment of upper respiratory conditions.
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