SOAP Note Format
SOAP Note Format
Name: Jane Hayes
Age: 34
Gender: Female
ID: 123456789
Subjective (S):
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Chief Complaint (CC): "I’ve been having a severe headache for the past 3 days."
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History of Present Illness (HPI): The patient reports a persistent, throbbing headache primarily on the right side of the head, with moderate nausea but no vomiting. The headache started 3 days ago and has worsened despite over-the-counter pain medication. No recent trauma or significant changes in vision.
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Review of Systems (ROS): Denies fever, chills, or photophobia. No recent changes in weight or appetite.
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Past Medical History (PMH): Generally healthy; no chronic conditions.
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Social History (SH): Non-smoker, occasional alcohol use. Works as a software engineer with frequent computer use.
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Family History (FH): Mother with a history of migraines.
Objective (O):
Vital Signs:
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Blood Pressure: 118/76 mmHg
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Heart Rate: 72 bpm
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Temperature: 98.6°F
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Respiratory Rate: 16 breaths/min
Physical Examination Findings:
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General: Alert and oriented, no acute distress.
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Head: Tenderness noted on the right temporal area.
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Eyes: No abnormalities; pupils equal, round, and reactive to light.
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Neurological: No focal deficits; normal strength and sensation.
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Laboratory and Diagnostic Results: No recent lab tests or imaging studies performed.
Assessment (A):
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Diagnosis: Likely migraine headache based on the unilateral location, throbbing nature, and associated nausea.
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Clinical Impressions: Possible trigger could be related to prolonged computer use.
Plan (P):
Treatment Plan:
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Prescribe sumatriptan 50 mg orally as needed for headache.
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Recommend over-the-counter ibuprofen 400 mg every 6 hours as needed.
Follow-Up:
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Schedule a follow-up appointment in 2 weeks to reassess the headache and response to treatment.
Patient Education:
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Advise on migraine triggers and suggest regular breaks from computer use.
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Encourage maintaining a headache diary to track frequency, duration, and potential triggers.
Prepared by:
[Your Name]
[Your Company Name]
