Free Family Practice Soap Note Template

Family Practice Soap Note

Prepared by: [Your Name]

I. Subjective (S)

A. Chief Complaint

The patient reports experiencing a persistent cough and fatigue for the past 7 days.

B. History of Present Illness

The patient, a 45-year-old male, states that the cough is non-productive and worse at night. He rates his fatigue level as 7/10 and reports difficulty performing daily tasks. He denies fever, chills, or shortness of breath.

C. Past Medical History

  • Hypertension is controlled with medication (Lisinopril 10 mg daily).

  • Seasonal allergies.

D. Medications

  • Lisinopril 10 mg daily.

  • Loratadine 10 mg as needed for allergies.

E. Allergies

  • Penicillin (rash).

F. Social History

  • Non-smoker, no alcohol use.

  • Works as an accountant with, a sedentary lifestyle.

G. Family History

  • Father: Hypertension.

  • Mother: Diabetes type 2.

II. Objective (O)

A. Vital Signs

  • Blood Pressure: 128/84 mmHg.

  • Heart Rate: 78 bpm.

  • Respiratory Rate: 18 breaths/min.

  • Temperature: 98.6°F.

  • Oxygen Saturation: 97% on room air.

B. Physical Examination

  • General Appearance: Alert and oriented, appears slightly tired.

  • HEENT: No nasal discharge, throat mildly erythematous without exudates.

  • Lungs: Clear to auscultation bilaterally, no wheezes or crackles.

  • Cardiovascular: Regular rhythm, no murmurs.

  • Abdomen: Soft, non-tender, no masses.

  • Extremities: No edema.

C. Diagnostic Results

  • Rapid COVID-19 test: Negative.

  • Chest X-ray: Pending.

III. Assessment (A)

  1. Likely a viral upper respiratory infection (URI).

  2. Fatigue related to viral illness or sedentary lifestyle.

  3. Hypertension is controlled.

IV. Plan (P)

A. Medications

  • Prescribed guaifenesin 200 mg twice daily for symptomatic relief.

  • Advised to continue Lisinopril and Loratadine as directed.

B. Diagnostics

  • Awaiting chest X-ray results.

C. Patient Education

  • Encouraged increased fluid intake and rest.

  • Discussed the importance of physical activity and considering a mild exercise routine once symptoms resolve.

D. Follow-Up

  • Return in 7 days or sooner if symptoms worsen or new symptoms develop.


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