SUBJECTIVE: The patient is here today with a tick bite on his upper right anterior thigh. He removed it last night and notes that the tick was quite tiny. He is complaining of muscle aches and joint pains. He does not note any fever. He notes that the area around the bite is now erythematous with central area purulent material and blistering.
OBJECTIVE: Blood pressure 140/74. Temperature is 98.8. Skin: On the anterior right thigh, there is a vesicular lesion with surrounding erythema, which is indurated and tender.
ASSESSMENT: Tick bite.
PLAN: The patient is given doxycycline 100 mg one b.i.d. for 21 days. He will follow up if his symptoms persist.
SOAP Note Sample Report #2
PROBLEM: Infected leg wound.
SUBJECTIVE: This (XX)-year-old patient returns after having one dose of cephalexin. His wife performed local wound care. He is now here for a recheck.
OBJECTIVE: This is an elderly gentleman with dialysis shunt in the right arm. Temperature 96.8 degrees. The left leg, the affected leg, looks much improved. Erythema is minimal. The wound has only a small amount of superficial purulence and made a remarkable recovery overnight.
ASSESSMENT: Healing leg wound.
PLAN: Repeat wet-to-dry dressing today to remove the last bit of dead skin and purulence over the abrasion. The patient will take a second dose of cephalexin after his dialysis on Monday and return as needed.
SOAP Note Sample Report #3
CHIEF COMPLAINT: The patient is here in followup to her pityriasis rosea.
SUBJECTIVE: The patient was last seen in Dermatology about a month ago. At that time, she had given a history of having started a rash in mid February, following mild cough and congestion for a few days but no fever. She had an extensive lesion of pityriasis rosea; although, the patient was not particularly itchy at the time. The patient was advised to continue to use the over-the-counter Aveeno Anti-Itch emollient, and she was also given Lidex ointment to be applied twice a day as needed. The patient returned and stated that she is no longer having any new lesions and they have resolved and the last ones to resolve were the ones on her arm since they were the last ones to occur and she continues to use Aveeno Anti-Itch just due to dryness of the upper arms.
OBJECTIVE: The patient is alert, oriented, well-nourished, appears to be in no acute distress. Focus of skin exam was her face, back, chest, abdomen, arms, legs, hands and feet bilaterally. The patient’s rash is noted to be completely resolved. There are no areas of annular erythematous macules any longer and no sign of postinflammatory hyperpigmentation. It is noted that, on the patient’s upper back, she does have a mild sun burn.
ASSESSMENT AND PLAN:
1. Resolved pityriasis rosea. The patient is advised that it was viral in origin and she may continue to use the Aveeno cream for an emollient. The patient is advised that at some point there is a possibility, years down the road, that if her immunity to this virus had abated that she may get this viral rash again.
2. In view of sunburn, the patient is advised to use sunscreen on a regular basis when going outdoors, even on cloudy days when it is warm, because she may still get a sunburn at that time.
SOAP Note Sample Report #4
SUBJECTIVE: The patient presents in followup for his left femur injury. He is approximately three months status post ORIF of a left periprosthetic femur fracture with allograft. He has been compliant with a partial weightbearing status. At this point, he has no hip, groin, trochanteric, buttock, or thigh pain. He is still somewhat troubled by his right footdrop, which he has had for quite some time before his acetabular fracture. He has not been wearing a brace for this. He has been taking Coumadin for venous thromboembolism prophylaxis.
OBJECTIVE: On evaluation of the left lower extremity, surgical incision is healed. There are no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch distally. He is able to actively dorsiflex and plantarflex the left foot and toes against gravity. The knee extensor mechanism is intact. There is no pain with passive range of motion of the left hip. He is able to actively dorsiflex the right foot and toes against gravity. However, he has complete dorsiflexion.
Radiographs of the left hip and femur demonstrate no change in fracture alignment or implant position. There is a well-fixed, well-aligned left total hip arthroplasty.
ASSESSMENT AND PLAN:
1. Three months status post open reduction and internal fixation of periprosthetic left femur fracture.
2. Status post complex left primary total hip arthroplasty. The diagnosis was described in detail to the patient. At the present time, clinically and radiographically, his fracture continues to progress toward union. We will advance him to weightbearing as tolerated at this point. We will give him a prescription for outpatient physical therapy, including aquatic therapy. He can discontinue the Coumadin. We will see him back in eight weeks’ time for repeat clinical and radiographic evaluation with AP and lateral radiographs of the left hip and femur. We have also given a prescription for an AFO for the right lower extremity.
SOAP Note Sample Report #5
SUBJECTIVE: The patient is here for an unscheduled visit with her father. She is complaining of left knee pain and some intermittent swelling. She has had arthroscopies of both knees, which showed some arthritic change, particularly patellofemoral. The patient did well with debridement on the right. Left side has not done quite as well.
OBJECTIVE: On exam today of her knees, she has a little bit of swelling, may be very mild, grade 1, and good range of motion. Little patellofemoral pain and a little patellofemoral crepitus.
X-rays were taken, which really looked pretty good.
ASSESSMENT: There is some evidence of old Osgood-Schlatter’s, which has been present previously. Otherwise negative.
PLAN: We will see how she does. We will see her back in a few weeks. If things are still bothering her, we certainly can consider a steroid injection.
NOTE: SOAP is an acronym for subjective, objective, assessment, and plan. SOAP format reports generally have these four major headings plus/minus other headings occasionally.
