This sample SOAP note demonstrates a standard format used by Nurse Practitioners (NPs). Remember, this is a sample and should be adapted to reflect the specific details of each patient encounter. Always adhere to your institution's guidelines and legal requirements when documenting patient information. This is not a substitute for proper medical training and practice.
Patient: Jane Doe, 45-year-old female
Date: October 26, 2023
Time: 10:00 AM
S: Subjective
Patient presents today complaining of a persistent cough for three weeks, accompanied by shortness of breath, especially with exertion. She denies fever, chills, or chest pain. She reports increased fatigue over the past month and states that her cough is worse at night. She denies recent travel or exposure to sick individuals. She reports a history of asthma, well-controlled with albuterol inhaler as needed. She denies smoking but reports occasional exposure to secondhand smoke at home. She states she’s been using over-the-counter cough suppressants with minimal relief. She asks about possible causes and treatment options.
O: Objective
Vitals: BP 120/80 mmHg, HR 88 bpm, RR 18 breaths/min, Temp 98.6°F (oral), SpO2 97% on room air.
HEENT: Normal
Lungs: Clear to auscultation bilaterally, except for occasional scattered rhonchi in the bases.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
Abdomen: Soft, non-tender, non-distended.
Extremities: No edema.
Pulmonary Function Test (Spirometry): (If performed - include results here, e.g., FEV1, FVC, FEV1/FVC ratio) Note: Results would be included here if a PFT was administered during the visit.
A: Assessment
Based on the subjective and objective findings, a likely diagnosis is acute bronchitis. The persistent cough, shortness of breath, and occasional rhonchi suggest lower respiratory tract involvement. Given her history of asthma, consideration is given to possible exacerbation, although her current symptoms do not suggest severe bronchospasm. Differential diagnosis also includes pneumonia, but the absence of fever and significant shortness of breath makes this less likely.
P: Plan
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Medication: Continue albuterol inhaler as needed for symptom relief. Prescribe a course of Doxycycline 100mg twice daily for 7 days to treat potential bacterial infection, given the persistence of the cough. (Alternatively, another appropriate antibiotic based on local resistance patterns could be prescribed). Recommend over-the-counter guaifenesin to assist with mucus clearance.
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Education: Instruct the patient on the importance of adequate hydration and rest. Educate her on the proper use of her inhaler and the importance of completing the antibiotic course. Counsel her on strategies to minimize secondhand smoke exposure.
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Follow-up: Schedule a follow-up appointment in one week to assess symptom improvement and evaluate treatment effectiveness. Advise the patient to return sooner if her symptoms worsen or if she develops a fever, increased shortness of breath, or chest pain.
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Further testing: If symptoms persist or worsen after initial treatment, further investigation such as a chest X-ray may be warranted.
Note: This is a sample SOAP note. The specific information included will vary based on the individual patient encounter. Always ensure accurate and complete documentation. Consider adding sections such as “allergies” and “medications” to the Objective section, as relevant.
