Chest Pain Soap Note

SOAP Note

Prepared by: Brian J. Burroughs, Silver Lining Software

This is a systematic SOAP note detailing the evaluation and management plan for Abigail King experiencing chest pain. This template ensures a focused and effective approach in treating and monitoring her condition.

Subjective

Objective

Assessment

Plan

  • 26 years old female, 5'4", 118 lbs.

  • Reports of intermittent chest pain

  • No known medical history

  • Non-smoker, occasional drinker

  • BP 120/80, HR 70

  • Alert, oriented, comfortable at rest

  • Chest examination normal

  • No sign of distress

Possible etiologist of chest pain. It could be due to cardiac origins or non-cardiac origins such as musculoskeletal, pulmonary, GI or psychogenic causes. Further testing required to determine origin.

Recommending chest X-Ray, ECG and possible cardiac enzymes testing. Consider referral to cardiology if tests are positive. Advising patient to monitor symptoms and return immediately if they worsen.

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