Soap Note Example

SOAP NOTE ID: 33 y/o M w/ PMH of substance abuse p/w perforated duodenal ulcer s/p Graham’s patch on 4/10/15. S: Pt doing well and resting comfortably. Pt states his pain is 8/10 around abdominal midline incision. Pt denies any fevers, nausea, vomiting over night. O: Vitals- Tm 99.5 @ 1400 4/9 Tc 98.7 BP 112/82- 143/88 P 85-102 RR 16-18 100% on RA Gen: Pt in no acute distress. Resting comfortably. HEENT: EOMI, PERRLA, no masses, no thyromegaly CV: Tachycardic, regular rhythm, normal S1, S2, no murmurs, rubs, or gallops Pulm: CTAB, no wheezes, rhonchi or crackles GI: Non-tender, Non-distended, tender to palpation along midline incision Neuro: A & O x4, CN II-XII grossly intact, no focal deficits MSK/Ext: Moves all extremities spontaneously, 5/5 strength, no edema, no cyanosis A/P: 33 y/o M w/ perforated duodenal ulcer s/p Graham’s patch on 4/10/15. 1) Perforated duodenal ulcer s/p Grahams patch a. Wound healing well, wrapped in krilex and gauze, no active bleeding, no pus, no erythema, no signs of infection. Continue wound care. b. JP drains- 5ml of serosangenous fluid. Continue to monitor for abnormal fluid. Monitor fluid collection. 2) Tachycardia likely secondary to pain vs. infection a. Pain well controlled on morphine and Norco10. Continue pain management. b. Pt afebrile. Monitor patient for fevers/signs of infection. Continue Abx therapy. 3) H/o substance abuse a. Social services to discuss rehabilitation. b. Encourage patient to quit substance abuse.

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SOAP NOTE

ID: 33 y/o M w/ PMH of substance abuse p/w perforated duodenal ulcer s/p Graham’s patch on 4/10/15. S: Pt doing well and resting comfortably. Pt states his pain is 8/10 around abdominal midline incision. Pt denies any fevers, nausea, vomiting over night. O: Vitals- Tm 99.5 @ 1400 4/9 Tc 98.7 BP 112/82- 143/88 P 85-102 RR 16-18 100% on RA Gen: Pt in no acute distress. Resting comfortably. HEENT: EOMI, PERRLA, no masses, no thyromegaly CV: Tachycardic, regular rhythm, normal S1, S2, no murmurs, rubs, or gallops Pulm: CTAB, no wheezes, rhonchi or crackles GI: Non-tender, Non-distended, tender to palpation along midline incision Neuro: A & O x4, CN II-XII grossly intact, no focal deficits MSK/Ext: Moves all extremities spontaneously, 5/5 strength, no edema, no cyanosis A/P: 33 y/o M w/ perforated duodenal ulcer s/p Graham’s patch on 4/10/15.

1) Perforated duodenal ulcer s/p Grahams patch a. Wound healing well, wrapped in krilex and gauze, no active

bleeding, no pus, no erythema, no signs of infection. Continue wound care.

b. JP drains- 5ml of serosangenous fluid. Continue to monitor for abnormal fluid. Monitor fluid collection.

2) Tachycardia likely secondary to pain vs. infection a. Pain well controlled on morphine and Norco10. Continue pain

management. b. Pt afebrile. Monitor patient for fevers/signs of infection.

Continue Abx therapy. 3) H/o substance abuse

a. Social services to discuss rehabilitation. b. Encourage patient to quit substance abuse.