NUR 634 SOAP Note

Patient SOAP Note Charting Procedures

S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not
signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term
“subjective” as opposed to “objective”. Normally, the practitioner is not aware of this
information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable
and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not
aware of this information until the practitioner elicits it. This might include, for example, ranges
of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments
about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any
treatment. Symptom code can be documented as assessment when pending final diagnosis such
as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined.
This may include both short and long term plans. It is important to record not only passive
therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active
therapy such as home care advice, exercises or other recommendations. All treatment planned
or delivered must be recorded.

SOAP NOTE TEMPLATE

Student Name: Date: Course:
Subjective:
Patient Demographics:
Age 34year old
Gender Male
Ethnicity Caucasian
Chief Complaint: “My eyes have been red and removing some dirt at the corner of the eyes for
three days now”
History of Present illness:
The patient was well until three days ago when he started having irritation in the eyes. The
symptoms were of gradual onset as he reports that it began as a mild irritation with a gritty
feeling under the eyelids. The eyes then started tearing and became very red, he later reported
that the eyes started collecting some white discharges at the corners of the eyes. Both eyes were
affected, having started with the left eye, then to the right eye. The symptoms have lasted for
three days. He reports that the irritation was characterized by itchiness, a gritty feeling and puffy
eyes in the morning especially. The symptoms are aggravated by rubbing the eyes, this worsened
the puffy eyelids. He took ibuprofen to relieve the pain and reports that the symptoms persisted.
He reports an associated headache on the temporal and excessive tearing. The severity on a scale
of 1-4, 4 being the most severe, he said it was a 3.
PMH: He was admitted in 2020 due to Kidney stones.
He developed Acute kidney injury during that time, but it resolved.
He has frequented the outpatient due to recurrent urinary tract infections.
No other admissions reported
No history of blood transfusion
PSH:
He underwent percutaneous nephrolithotomy in 2020 following a diagnosis of Kidney stones.
Surgery was successful with no complications
Allergies:
He has no known food or drug allergies.
No known environmental allergies.
Recent over the counter medications were Ibuprofen 400 mg thrice daily for relieving headaches.
He does not use supplements.
Untoward Medication Reactions:
He has no known allergies or reactions to drugs.
Immunization Status:
He received all childhood immunizations as required.

Has not received the annual flu shot, due in May 2022
He received both COVID vaccines in October and November 2021.
Screenings: He does a routine Urinalysis, last results showed some traces of red blood cells.
He is due for a urologist review.
FMH: He is a Father of two children all alive and well, married and lives with the wife. His
father has chronic kidney disease, mother is a known asthmatic patient. His maternal
grandparents died due to hypertension related complications . Paternal grandmother alive and
well, grandfather alive and lives with Diabetes.
Personal History/Social History: He works at the bank as a clerk, and lives in an urban area
with his family. The area has a low crime rate. He eats a relatively balanced diet and avoids
refined foods . He stays fit by cycling but does not exercise much.
He does not use any illicit drugs, occasionally drinks beer on the weekends.
Females: N/A
Sexual History: He has a wife and a girlfriend. Uses protection with the girlfriend.
Current Medications/OTCs/Supplements: He has used Oral Ibuprofen 400 mg thrice daily for
the last two days
Review of Systems:
General:
Has general body malaise. Normal appetite, no weight loss.
HEENT:
Head: Has a persistent headache, temporal. No reported lumps or sores.
Eyes: eye discharge and red eyes excessive lacrimation.
Ears: No ear pain, no ear discharge, no impaired healing.
Nose:No running nose, no nasal discharge.
Throat:No reported sore throat. no voice hoarseness, no lumps in the throat.
Respiratory: No cough, no chest pain, no shortness of breath, no dyspnoea.
Cardiovascular:No chest pain, no dyspnoea, no exertional dyspnoea
Genitourinary: Hematuria reported

Objective:
Physical Exam:
Vital Signs: Blood Pressure- 110/76mmHg P- 89beats/min RR- 14 breaths/min T-36.8
Height- 179cm Weight- 92kg BMI-28
General:

Fair general condition, oriented with time, place, and person. Normal gait and posture Not in
obvious distress. No pallor, no jaundice, no cyanosis, no lymphadenopathy, no
oedema.
HEENT:
Head: Normal shape and size. No visible scars or masses, No palpable masses or tenderness
Eyes: Red eye, Pupils bilaterally reactive to light, Extraocular movement
intact. Visible purulent eye discharge, cream yellow in color. lacrimation present
Ears: Normal ear shape, no visible canal inflammation, no visible discharge. hearing
normal in both ears.
Nose: Patent, symmetrical, no visible nasal discharge, no inflamed sinuses. Sense of smell is
intact.
Throat: Mouth centrally placed, normal denture, no visible sores or lumps, no inflamed tonsils.
Neck: no visible lumps or swellings. trachea centrally placed, no carotid bruits. No palpable
masses or lymph nodes
Lungs: Chest moves with respiration.Vesicular breath sounds.
Heart: S1 S2 heard

Assessment:
Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential
diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required
below the table.
Differential
Diagnoses

Pathophysiology
(include APA
citations)

Pertinent Positives Pertinent Negatives

1. Bacterial
   conjunctivitis

inflammation of the
conjunctiva caused
by
infection. Presents
with periorbital
oedema, Hyperemia
affects one
eye and then the next.
eye discharge is
present, discharge is
usually purulent.
(Ryder et al,
2021)

Purulent discharge,
hyperemia, eyes
swollen

no preauricular
lymphadenopathy. no
watery discharge. no
associated running
nose.

2. Viral
   Conjunctivitis

This causes
conjunctival
inflammation caused
by a virus. Presents
with watery
discharge, Running

Red eyes, watery
discharge,
rhinorrhoea, burning
sensation.
preauricular
lymphadenopathy

discharge is watery
not purulent.

nose hyperemia and
inflamed
eyelids(Roat, 2021)

3.Allergic
conjunctivitis

Allergens usually
cause inflammation
to the conjunctiva.
presents with
Hyperemia, stringy
discharge and
lacrimation. usually
resolves in a day or
two. (ada,”
n.d.2022)

Lacrimation, red
eyes, swollen eyes

absence of purulent
discharge

4.
5.
Diagnosis
Bacterial conjunctivitis.
This presents with reddened eyes, purulent discharge, copious amount and swelling eyes(Ryder
et al, 2021). Patient symptoms were differentiated from viral and allergic
conjunctivitis due to the discharge present, it was cream yellow and purulent(Ryder et al, 2021)..
Its associated factors were a headache on the temporal lobes, unlike in viral and
allergic conjunctivitis where there is mild or no headaches, there was excessive tearing but no
running nose noted(Roat, 2021).Preauricular lymphadenopathy is in viral conjunctivitis (ada,”
n.d.2022) and this patient has no lymphadenopathy .On inspection, the eyes had hyperemia and
purulent discharge(Ryder et al, 2021).
Plan:
The patient is a known patient with recurrent kidney stones, he presented with swollen eyes and
discharge at the corner of the eyes. He described the discharge as cream in color and also
reported that his eyes have been tearing more than usual. He reports to also have a persistent
headache on the temporal lobes. On inspection he had hyperemia, swollen eyes and cream
yellow discharge that was copious. His sight however, has not been affected.
(APA citations required in your plan)
Diagnosis Bacterial conjunctivitis (ICD 10 code H10.89)
Diagnosis ICD-10 (must be related to CC/HPI)
● Treatment
Supportive management.
-Reassure the patient that the conjunctivitis will resolve
-Emphasize on drug compliance
Medical Therapy

-Topical Eye drops or Eye ointments with antibiotics are preferred. For mild to moderate
bacterial conjunctivitis, older antibiotics like cotrimoxazole can be given, moderate to severe
conjunctivitis give newer generation antibiotics like levofloxacin.(Ryder et al,2021)
-Eye ointments like erythromycin and ciprofloxacin may be given.(Ryder et al,2021)
-Give an oral tylenol for relieving headaches
● Lab/test
-A swab of discharge for culture and sensitivity can be done in severe cases to rule out
gonococcal conjunctivitis (Ryder et al,2021)
-A rapid adenovirus test can be done to rule out viral conjunctivitis(Ryder et al,2021)
● Referral
-Refer patients with vision interference, excessive discharge and corneal involvement. They
should visit an ophthalmologist.(Ryder et al,2021)
-Patients with recurrent conjunctivitis should also be referred.
-Patients who wear contact lenses, those with photophobia and those that require steroid therapy
are a high risk group and should be referred.(Ryder et al,2021)
● Education
-Educate the patient on hand hygiene as it is easily transmitted.
-Education on proper use of eye drops and handling the dropper is key to prevent reinfection or
contamination.
-Compliance with medication is important and should be emphasized.
● Follow up

-A follow up in three days to ensure symptoms are resolved is important.

-He should return should the symptoms worsen.
Health Maintenance:
He should drink plenty of water, maintain a healthy low calorie diet
He should keep up with the routine urinalysis checks.
Exercise is important
He is advised to avoid alcohol use.
RTC: (Document disposition)

References
Roat. (2021, April). Allergic conjunctivitis – Eye disorders – MSD manual consumer
version. Retrieved from https://www.msdmanuals.com/home/eye-disorders/conjunctival-
and-scleral-disorders/allergic-conjunctivitis
Ryder et al. (2021, July 18). Conjunctivitis – StatPearls – NCBI bookshelf. Retrieved
from https://www.ncbi.nlm.nih.gov/books/NBK541034/
Viral conjunctivitis « ada. (n.d.). Retrieved from https://ada.com/conditions/viral-
conjunctivitis/

• Key: CC = Chief complaint; HPI-History of Present Illness. With pain and many symptoms- an approach that is helpful is
  OPQRST: Symptom analysis- Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing (history). Be sure to give the
  “story of the symptom or complaint. However, simply listing each of these will not always tell the complete story of the HPI. Step
  back, read what you wrote and make sure it is clear and complete.