SOAP Note Example for a Telehealth UTI Visit

What should be included in the Subjective section?

In the subjective section, document what the patient tells you. This includes their main complaint and any symptoms they're experiencing. Ask about the duration and severity of symptoms, and if they've had UTIs before.

• Chief Complaint: Burning sensation during urination.
• History of Present Illness: The patient reports a 3-day history of dysuria, increased frequency, and urgency. No fever or back pain.
• Past Medical History: Previous UTI one year ago, treated with antibiotics.
• Medications: Currently taking oral contraceptives. No recent antibiotic use.
• Allergies: None known.

What goes in the Objective section for a telehealth visit?

In a telehealth setting, the objective section may be limited since you can't perform a physical exam. Focus on observations you can make through the video call and any home measurements the patient can provide.

• General Appearance: The patient appears well and in no acute distress.
• Vital Signs: Patient reports temperature of 98.6°F, no fever.

How do you write the Assessment section?

The assessment is your diagnosis based on the subjective and objective information. Include your reasoning here.

• Diagnosis: Uncomplicated urinary tract infection.
• Rationale: Symptoms consistent with UTI. No signs of pyelonephritis (e.g., fever, flank pain).

What should the Plan section cover?

The plan outlines your treatment strategy. Include medications, follow-up instructions, and any lifestyle advice.

• Medications: Prescribe Nitrofurantoin 100 mg orally twice daily for 5 days.
• Patient Education: Advise increased fluid intake and cranberry juice may help.
• Follow-Up: If symptoms persist or worsen, follow up in 48-72 hours.

Remember, a SOAP note is a structured way to ensure you cover all necessary information. It helps in providing consistent care and facilitates communication between healthcare providers.