Sample soap note for dizziness Initial Prenatal Visit (First OB antepartum) Subjective (S) Demographics: 19 yo G1P1000 @ 10w2d by Denies dizziness, HA, visual disturbances, and edema. Patient states he is dizzy at times while sitting but it worsens when he stands. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. SOAP notes for Mental Health Examples Neurological: Denies headaches, dizziness, confusion, or weakness. She describes the headaches as throbbing in nature, located primarily in the frontal region, and exacerbated by stress. A 65-year-old woman presents to her primary care phyisican for dizziness. ” History of Present Illness: Mrs. txt) or read online for free. Module 8 SOAP Note– Focused Cough Assessment. That's why we've taken the time to collate some examples and SOAP note templates we think will help you write more detailed and concise SOAP notes. docx from NURS 650 at Pace University. Patient Information: Initials Age, Sex, Race. com writers can help. Respiratory: denies coughing, wheezing, dyspnea. It aims to reduce daily This post includes 35 examples of SOAP notes for mental health examples and an outline to get you started. HPI: 87-year-old female presents today due to concerns of having an unsteady gait and general weakness for the past 3 months. The Perfect SOAP Note Example – Female, 33, “My back hurts” Posted by Dr. IDinfo:29yearoldG2P1001Caucasianfemale CC:prenatalvisitat19+6weeks Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. Does not wake during night or nap during day. The document is a 6-page SOAP note for a 39-year-old female patient presenting with nausea, vomiting, and abdominal cramps for 2 days. Vital Signs: BP 132/80 mmHg, HR 98 bpm, RR 18 SOAP NOTE school of nursing subjective chief complaint: having right sided ear history of the present illness (hpi): is 26 asian female who presents to the ent Sample - SOAP NOTE. ” HPI: Cough: X 7 days. Patient/Client Details. Laboratory tests confirm the diagnosis. Whether it’s managing anxiety, addressing grief, working through procrastination, or exploring self-esteem, these examples show how the SOAP format captures essential session details for various client needs. Psychologic: Reports having auditory and visual hallucinations. : Acquired Hypothyroidism Followup Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus. PMHx: acid reflux, hypertension, hyperlidemia, glaucoma Family Hx: Mother deceased 46 colon cancer, Father deceased 76 focused soap note subjective cc: am tired all the time and my hair is falling hpi: patient is 43 year old african american woman presenting to the clinic to. week 6 soap notes for neurological sick visit examination create cc. Denies abdominal pain. See how effortless clinical note automation can improve your practice. Wilson. Skin: Denies rash, wounds, pallor, mass, capillary bed changes, or pigmentation. (Subjective) CC (Chief Complaint): “Mild earache for 2 days” HPI (History of View Sample SOAP Note . HPI: Intermittent dizziness for 1 month. HEENT: Slight hearing loss, mild ear pain on the right ear, slight hearing loss, No sneezing, congestion, runny nose or sore throat. The patient stated, “I’ve been feeling very tired lately. Home; Services. 0 % 0 Assess. S: Patient reports increased pain in the Women’s Health SOAP Note Example Please refer to the SOAP Note Format guide that is located in the itching, dryness, changes in color, or changes in hair or nails HEENT: Head - Denies headaches, dizziness, NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. University; Neuro: Denies headache, dizziness, confusion, slurred speech, change in. Rachel Andel Denies changes in orientation, memory, insight, or judgment. PACE UNIVERSITY COLLEGE OF HEALTH PROFESSIONS LIENHARD SCHOOL OF NURSING DEPARTMENT OF GRADUATE STUDIES NURS 650 SAMPLE SOAP NOTE Date: Neuro: Denies headache, dizziness VITALS. No recent URI, fever, chills, weight loss or night sweats. had sex for the first time yesterday, condom less oral sex w a male partner. Sleeping more than previously, approximately 9 pm to 7:30 am, but does not feel rested. is on medicine continuously and SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. Neurologic: Alert and oriented x3, cranial nerves intact, no loss of sensation Through real SOAP note examples and expert tips, you’ll see how structured notes can save you time, enhance communication, and contribute to the highest standard of patient care. Admits to X as per HPI. Quill offers a range of SOAP note examples that demonstrate how each section can be applied to different therapy scenarios. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or Date and Time S. 2 The PLAN section of a SOAP note plays an integral role in showing the clinical reasoning and decision-making skills of a PMHNP or APRN. Subjective: Client’s self-reported reasons for seeking therapy, current symptoms, emotional state, client report of progress towards goal, and personal history. 8/21. " History of Present Illness (HPI): Ms. Neck: No swollen glands, no neck pain. SOAP NOTE. Cifu, Diane Altkorn that related to my assigned topic I learned that there are four categories under which the experience of dizziness can fall: vertigo, disequilibrium, near Pediatric SOAP Note Example Patient Information. S. RV lives with his mother, father, sisters and brother. pdf), Text File (. , Practice materials. This short guide includes 3 SOAP note plan examples you can use when writing. docx), PDF File (. A Assignment Number: 4. Despite the emergence of electronic health records (EHRs) and other digital documentation methods, the SOAP format remains a popular and effective way to document patient encounters. Patient ID: 35F, otherwise healthy, from home Subjective: The patient is a 35-year-old female who presents with a sore throat for the past 4 days. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of hypertension, migraines, SOAP NOTE Benign Paroxysmal Positional Vertigo CC: Dizziness for the past three days S) HPI: 64-year-old, white male presents with dizziness for the past Write a soap note for 57 yr old male with the present illness of dizziness. View Lecture Slides - Prenatal+Visit+SOAP+Note+Sample. SUBJECTIVE: The patient relates that he was hit in the head by a baseball, which was thrown by another player and it hit him on the top of the head while he was picking up another ball, which had rolled over to him from two other players who were having a catch. 6. None. Takes 25 mg of sertraline once daily to treat post-traumatic stress disorder. O: (see Assessment Section) A: 132: maternal wt loss; 301: hyperemesis gravidarum EXAMPLE #1: Patient with Urinary Tract Infection (Family Nurse Practitioner SOAP Note) Date: 10/01/23 Pt. Struggling to do your SOAP Note, thestudycorp. she states that she feels somewhat. Denies significant headache, visual symptoms, stiff neck. History of Present Illness A 41 y. BP 150/88 mmHg, HR 80bpm, Resp: 14breaths/min, SOAP Note Example 1 S: Faces, client states that she feels badly because she has morning sickness and nausea when she eats. is a 21 y/o white female who presents to the clinic today with complaints of frequent, burning, painful urination. He states that he has been under stress in his workplace for the last month. A. doc / . Advanced Example: New OB SOAP Note. Admits weakness and lightheadedness. All you need to do is place an order with us. He reports an intense spinning sensation causing nausea and vomiting. Capstone Project Help; Nursing Assignment Help; Statistics Assignment Help; 70-year-old Male with BPPV SOAP Note Example: CC: Dizziness. The patient states that the symptoms first occurred when rolling over in bed. Estimated stay 3-5 days sample SOAP note - Free download as Word Doc (. Here are SOAP note examples to help document and track client progress. ROS: Denies chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg edema, leg pain, leg trauma, dizziness or palpitations. Plan: See More Samples on SOAP / Chart / Progress Notes. She approached the receptionist who immediately called for the MA. SOAP Notes. PHYSICAL EXAMINATION: WD, WN. The sensation lasts 1 minute. COMMUNITIES MB 2/3 Step 2 & 3. Focused SOAP Note Date of encounter: 1/8/2023 Patient Initials: SG Informant: patient is a reliable historian. Cancel Save. Try IntakeQ free for 14 days and see how automation can transform your patient care. Darby has a passion for caring for veterans and a special Document a SOAP Note Name: __ Charlotte Caceres _____ Date: __11/26/23_____ Try it Yourself! Patient Scenario: Mrs. Appetite ok. Skip to document. Initials: J. Pt states he has also been nauseated at times during the dizzy spells. ” Patient states his oncologist sent him for a blood transfusion. He states that he has been under stress in his workplace for the last month. VITAL SIGNS Head: Negative for dizziness, headaches, or loss of consciousness. It’s important that SOAP notes, or notes in any template style follow the requirements of a progress note, such as including session details like the start and Soap Note: Dizziness HPI: B. Darby lives in Louisiana and loves exploring the state’s rich culture and history. No abdominal pain, change in bowel habits, black tarry stools, bright red blood per rectum. Her symptoms began while lying in bed, and when she turned her head to the side she had an abnormal spinning sensation. It aims to reduce daily Example 1: SOAP Note Format Example for Nurses Subjective. Objective. RV is a reliable source. VITAL SIGNS The Perfect SOAP Note: CC: “My back hurts”. C/o nausea and vomiting in early AM and after large meals. The treatment modalities that are included are school-based interventions, family therapy, parent management training, and individual child therapy. By . under review of system and physical, you should include all the components that are documented. , Age: 11, Sex: Male, Race: Not specified (additional inquiry needed) S. Psychotherapy is the first-line mode of Practice. Week 1 Lecture Notes - Advanced Health Assessment. : Allergic Rhinitis A 23-year-old white female presents with complaint of allergies. In this article, we will explore five different soap note examples to illustrate how they are Table of Contents: Long SOAP Note Example Short SOAP Note Example SOAP Notes Structure Subjective Objective Assessment Plan Other Info Tips for Writing SOAP Notes Common Abbreviations How do doctors organize all the information about their patients? Back in the 1950s, Lawrence Weed asked himself the same question and came up with a solution — SOAP SUBJECTIVE: ID: RV is a 74 year old male that came to the family clinic with his daughter. Neurological: Denies dizziness, headaches, lightheadedness, syncope, numbness or This post includes 35 examples of SOAP notes for mental health examples and an outline to get you started. Skip to content. SOAPIE Nursing Notes Examples Example 1: Subjective – Patient M. As I read through the cases in Symptom to Diagnosis: An Evidence-Based Guide, 3e by Scott D. Age: 52 years Sex: Male Source: Patient Allergies: None. Gradually worsening. She has tried eating small meals and that helps her nausea a little. Current Medications: Hydrochlorothiazide. Include the name of the patient, age, gender, and race. CC: Dizziness HPI: Pt is a 53 year old Caucasian male complaining of dizziness upon standing that began a few days ago. 100% (1) 2. Include at least two references for your diagnostic and treatment plan. Chief Complaint: 87-year-old female with complains of unsteady gait for 3 months. The player who threw the ball did not realize that he was bending over to pick up the SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. CPS 215 Final; Pfg - idk; L1 Homework 2024 - lAB 1; Jaw pain dizziness - Jaw pain SOAP note. Course: Patient care management Episodic/Focused SOAP Note Template Examples. 508 Advanced Health Assessment Final Study Guide. write 2 differential diagnosis and treatment plan Head: Positive for dizziness, Negative headaches/ loss of consciousness Neck: Negative for tenderness Eyes: Negative for vision changes; Positive use of glasses CDM - Dizziness Soap Note. 7 Treatment Jones (2018) highlighted that oppositional defiant disorder management is multimodal and should involve school, family, patient, and the community. M. write 2 differential diagnosis and treatment plan Louella Mesina, Student FNP S. Subjective: GP 67 yo male who was recently admitted to hospital for dizziness and severe hyperglycemia; need education/counseling since he was recently started on insulin therapy Write a soap note for 57 yr old male with the present illness of dizziness. HPI: 87-year-old female presents today due to concerns of having an unsteady gait and general weakness for the past Neurology SOAP Note Example Subjective: The patient is a 45-year-old female presenting with a chief complaint of persistent headaches and intermittent dizziness for the past month. Download Free SOAP Notes Templates [2025 updated] Patient complains of fatigue and occasional dizziness, denies bleeding or changes in Constipation SOAP Note – Week 6: Assessment of the Abdomen and Gastrointestinal System Constipation SOAP Note – Week 6: Assessment of the Abdomen and Gastrointestinal System Patient Information. Inpatient: Psychiatric. " History of the patient's illness: a 60-year-old female patient came into the clinic for an evaluation. J. Advanced pharmacology (MSN Soap notes are a type of documentation used by healthcare professionals to record patient information in a structured and organized manner. Denies loss of consciousness but complains of mild dizziness and nausea. Endoscopy in March was also negative for abnormal findings. When assigned to write a SOAP note on ADHD, based on either a case study, case scenario, snippet, or an actual case, you need to understand how to document it. Remainder of review of systems including the head, neck, chest, abdomen, extremities and neurological systems negative. Stern, Adam S. She reports Here is an example of a SOAP note for a patient who has had a stroke: Subjective: The patient is a 70-year-old male who was recently hospitalized for a stroke. Episodic/Focused SOAP Note Template Examples. P. CC: “I came to the clinic because I feel lightheaded and dizzy. The subjective section details the patient's medical history, social history, family history, and review of systems. Denies any dizziness, nausea, vomiting, or other neurological abnormalities. Keywords: soap / chart / progress notes, headaches and dizzy spells, chest pains, shoulder, progress, headaches, NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. SOAP / Chart / Progress Notes; Acne - SOAP Acne with folliculitis. His first episode occurred 3 days ago when he rolled over in bed. 43 y/o black female CC: “I am here today because I have a cough and sore throat. o caucasian female presents to the office for a follow-up on migraines. 0. Surgery History: None Current Medications: Uses ibuprofen PRN to treat chest discomfort and headaches. Pt is Medical Specialty: SOAP / Chart / Progress Notes Sample Name: Diabetes Mellitus - SOAP Note - 1 Description: Followup diabetes mellitus, type 1. is a 55-year-old female who presents to the neurology clinic with complaints of persistent headaches and episodes of dizziness CHIEF COMPLAINT: Headache. Soap Note STI Testing. SOAP Note Overview Notes. 1. pt is S. Name: Mary Parker Chief Complaint: Burning, frequent, painful urination Subjective: Patient M. note template for psychiatry S ubjective: Patient states, "some people are coming to get me. pdf from NURSING 442 at Duke University. SOAP NOTE Plan Examples 2. Occurs every few minutes. Here is a complete template of how to go about it. He presents to the clinic for a follow-up appointment. SOAP note example for Sample SOAP Note S: V. Denies dizziness/lightheadedness. A list of SOAP Note examples for clinicians in the USA. 0. Chief Complaint: STI testing Pain: 0/ Hx + ROS: HPI: here for STI screening. Abdominal soap note example. has a history of hypertension and high cholesterol; his father and paternal grandfather have a history of heart attacks. she carries her life like doll (as usual) whom Ch 13 - This is practice notes; Related documents. Write a soap note for 57 yr old male with the present illness of dizziness. Reports that the headache has resolved. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the Soap notes will be uploaded to Moodle and put through TURN-It-In Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. Patient reports taking Pepto Bismol prn with minimal relief. SG, a 76-year-old Caucasian female, presents with complains of dizziness episodes. Perfect for Physical Therapy, Occupational Therapy, Mental Health Therapy Notes, SLP, Nursing, Dentistry, Podiatry, Massage Therapy, Veterinary, Chiropractic, Acupuncture, Pharmacy Notes. The acronym “SOAP” stands for Subjective, Objective, Assessment, and Plan, which are the four main components of a soap note. "I’m tired all the time" HPI: 25 year old female complaining of increasing fatigue over about 4 months. For example: - Metoprolol may have been a good choice given the elevated HR - BP medication could also be changed to Carvedilol since it targets alpha 1 receptor - Change to Crestor 20 or 40 mg po daily or switch to Atorvastatin 40 or 80 mg po daily Here's a sample SOAP note: Subjective. Subjective. Mrs. Medical history: No known chronic conditions; no current medications. Snapshot. RV’s ethnic background is African American. 100% (6) 64. RV’s date of birth is 02/01/1948. D. Here’s Soap note nursing example 2 of SOAP Note ROS Review of Systems. Pt denies paresthesia, weakness, transient paralysis, seizures, syncope, dizziness, and headache Psych: Denies episodes of anxiety or depression; patient reports 2 Episodic/Focused SOAP Note Template Patient Information: DC, 53, Male, Caucasian S. She reports that the cough is productive with greenish sputum and the sore throat is painful and makes it difficult for her to eat and drink. Soap note 40 female cc: follow up hpi: female here to follow up on concerns of frequent heart palpations and dizziness. SOAP Note Examples Anxiety SOAP Note Example. Neurological: Headaches, dizziness, numbness. SOAP Note Example-Comprehensive. The subjective section is invaluable in setting the stage for a thorough, patient-centered approach to care. Explore our comprehensive collection of 10 common Social Worker SOAP note examples, designed to enhance your clinical documentation skills. D is 40 yof presenting with c/o fatigue x 2 months. Bloodwork done on 1/10/2019 shows H/H of 6. Denies fever/ chills. QNT 275 Practice Set 2; Week 4 Assignment: Emotional Intelligence (EI) - Nursing; Soap Note 1 Acute SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. GENERAL: no weight loss or gain, has fever, experiences chills, grandmother reports feeling warm on touch. It aims to reduce daily documentation times by up to 50%, and it provides the ability to create as SOAP Note #7. She has tried taking an anti-emetic, but it just makes her tired and dizzy. Feels tired all day, decreased interest in usual activities, less able to complete routine tasks, and generally slowed up. HPI: This is the symptom analysis section of SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. He denies other symptoms, medical history and The patient is a 45-year-old female presenting with a chief complaint of persistent headaches and intermittent dizziness for the past month. Denies dizziness. SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for Physical Therapy, Occupational Therapy, Mental Health Therapy Notes, SLP, Nursing, Podiatry, Massage Therapy, Veterinary, Chiropractic, Acupuncture, Pharmacy Notes. is a 68 year old male with no known allergies who presented to the ED two days ago with intermittent chest pain that had been lasting for 5 hours. Eats fruits and hydrates appropriately. Here are some examples of SOAP notes. ” HISTORY OF PRESENT ILLNESS (HPI): RV CDM - Dizziness Soap Note. Allergies: None. J reports that when he is dizzy, it feels as though the room is spinning. 1 Subjective History Chief Complaint Follow-up on migraines and increased dizziness. . R. write 2 differential diagnosis and treatment plan DATE OF VISIT: MM/DD/YYYY REASON FOR VISIT: Dizziness and vertigo. SOAP Note AI offers an AI assistant designed to help create SOAP Note and Progress Note templates for both telehealth and in-person sessions. Some widely used note-taking templates include: 1. MTHelpLine does not certify accuracy SUBJECTIVE HPI-ROS: The patient Prior to the visit, the patient's chart was reviewed for labs, radiology reports, and correspondence from other providers and facilities including hospitals. 0 Images. Lorie T. Joy Smith was waiting in the lobby when she suddenly felt faint. It aims to reduce daily Popular Therapy Note Templates with Examples. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length SOAP Note Example Subjective Data Patient Information Date: 7/10/2019 Patient Initials: TD Info Source/Reliability: pt is a reliable source Patients age/DOB/gender/race: 40 yof, Caucasian Insurance/self pay: BCBS Insurance Chief Complaint: “ I am tired all the time. (Medical Transcription Sample Report) CHIEF COMPLAINT: SOAP NOTE ON HYPERTENSION focused soap template student name: michele niedermeyer course: ngr6201l care of the adult practicum assignment: soap note: Chest/Cardiovascular: denies chest pain, palpitations, dizziness, peripheral edema. HEENT: Denies visual 15 SOAP note examples and templates Although the above sections help outline the requirements of each SOAP notes section, having an example in front of you can be beneficial. Stool sample collected, which was negative. With this template, you can easily: Document all four components of a SOAP note, including follow-up tasks like referrals and patient instructions No dizziness. It aims to reduce daily 5 Perfect Nursing SOAP Note Examples + How to Write Written By: Darby Faubion Darby Faubion RN, BSN, MBA Darby Faubion is a nurse and allied health instructor with over 20 years of clinical experience. They contain four primary sections, represented by its acronym: SOAP note example. Endocrine: Denies endocrine issues. Note Template Basic Information Site: Primary Care Service: Follow-up Date of Visit: 9/5/2024 Patient Initials: K. Smith tells you that she is not feeling well and is very dizzy and feels as though she is going to Note: The SOAP note can have other answers depending on the student’s thought process. Advanced Health Assessment. create an id, cc, hpi, ros, physical findings, and assessment with at least differential Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc. PMHX: Mr. Denies vaginal discharge, odor, bleeding, and cramping. Slender, 34-year-old white male. M. Eyes: No visual loss, blurred vision To help you get started, consider using tools that can assist in generating automated SOAP notes or here are some examples to guide you: Soap Note Example and Template for for Nurses. S: JM is an 87 yo male with PMH significant for leukemia with chief complaint of “weakness and lightheadedness. J is a 32-year-old man who comes to your office complaining of dizziness. MTHelpLine does not certify accuracy and quality of sample reports. Medical Specialty: SOAP / Chart / Progress Notes Sample Name: Diabetes Mellitus - SOAP Note - 1 Description: Followup diabetes mellitus, type 1. This guide covers a wide range of conditions frequently encountered in social work practice, including depression, substance use recovery, child neglect, domestic violence, geriatric care, crisis intervention, family therapy, ADHD SOAP Note Template for Nursing Students. P Age 31 Sex Female Race Caucasian Insurance Blue Cross Blue Shield S. Course. partner told him he had recent negative STI screening. Sample Type / Medical Specialty: SOAP / Chart / Progress Notes Sample Name: Diabetes Mellitus - SOAP Note - 1 Description: Followup diabetes mellitus, type 1. 2 Iron Deficiency Anemia Soap Note PATIENT INFORMATION: Name: J. SOAP Note FAQs What are SOAP notes and why are they SOAP Note Women’s Health Patient Information: Initials A. C. Recent Posts Talus Fracture Open Treatment Operative Sample Report Related Posts Neurology SOAP Note Sample Reports Neurology SOAP Note Medical Transcription Samples Axonal Sensory Polyneuropathy Chart For my first SOAP note I was assigned the topic of dizziness. Note Template Case ID #: 9082-20191014-016 Note 2 of 5 S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up Wondering how to write SOAP notes? Getting the SOAP format right is essential for therapists. Subjective: CC. Pt is currently living in an skilled nursing facility with 24 hour supervision since the passing of SOAP notes are a specific format for writing progress notes as a behavioral health clinician. Subjective Chief Complaint (CC): "I have been experiencing dizziness spell for weeks and I feel very afraid. It aims to reduce daily Jaw pain SOAP note subjective: hpi: is 65 female here today with her daughter for dizziness and new jaw pain. Last transfusion was 3 weeks ago. 3. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name Miami Regional University Date of Encounter: Preceptor/Clinical Family Medicine SOAP Outpatient Progress Note. Hair Loss SOAP Note Medical Sample Report. Private Note. , a 33-year-old man, presents to the clinic with complaints of dizziness that started three days ago. Chief Complaint (CC): A. No sweats. , denies anxiety has enabled her but becomes tearful, dizzy and tearful when discussing anxiety Given RX for Buspar - has not tried it yet, states she is scared of the side effects and Renal this is an example of soap note would like you to follow. O. ” The patient reports that “this fatigue is overwhelming” and that onset began approximately 3 months ago, making her Here is an example of a SOAP note for a patient with anemia: Subjective: The patient has symptoms consistent with anemia, including fatigue, weakness, shortness of breath, headaches, and dizziness. The patient is experiencing hallucinations and prefers to stay at her neighbor's house during the daytime and wait for her son at night, claiming that Yes, SOAP notes are still widely used in medical and healthcare settings. It aims to reduce daily This SOAP note template was created by a nurse practitioner to capture detailed SOAP notes, particularly for complex cases or when multiple issues are raised during a single visit.
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