Free Sample Soap Note Template
Sample Soap Note
Prepared by: [Your Name]
I. Subjective
A. Chief Complaint (CC)
The patient reports lower back pain for the past three weeks.
B. History of Present Illness (HPI)
The patient describes the pain as a dull ache in the lower back, aggravated by prolonged sitting and bending. Pain improves with over-the-counter pain medication but returns after a few hours. No radiation to the legs.
C. Review of Systems (ROS)
-
Musculoskeletal: No joint swelling or stiffness.
-
Neurological: No numbness or tingling.
-
Cardiovascular: No chest pain or shortness of breath.
D. Past Medical History (PMH)
-
Hypertension is controlled with medication.
E. Medications
-
Lisinopril 10 mg daily.
F. Allergies
-
No known drug allergies.
G. Family History
-
Father with osteoarthritis.
H. Social History
-
Non-smoker, occasional alcohol use, sedentary job.
II. Objective
A. Vital Signs
|
Vital Sign |
Measurement |
|---|---|
|
Temperature |
98.6°F |
|
Blood Pressure (BP) |
130/85 mmHg |
|
Heart Rate |
72 bpm |
|
Respiratory Rate |
16 bpm |
|
Weight |
180 lbs |
B. Physical Exam
|
Category |
Findings |
|---|---|
|
General |
Alert, no acute distress |
|
Musculoskeletal |
Tenderness over the lumbar spine |
|
Neurological |
Reflexes intact, no sensory deficits |
|
Range of Motion |
Limited flexion due to pain |
III. Assessment
A. Primary Diagnosis
-
Mechanical lower back pain.
B. Differential Diagnosis
-
Lumbar strain or degenerative disc disease.
IV. Plan
A. Treatment
-
Recommend ibuprofen 400 mg every 6 hours as needed.
B. Follow-Up
-
Return in 2 weeks to assess progress.
C. Referrals
-
Physical therapy evaluation.
D. Patient Education
-
Advise posture correction and stretching exercises.
