SOAP Note Example for Upper Respiratory Infection

What should the Subjective section include for a URI?

In the Subjective section, record what the patient tells you about their symptoms and history. Ask open-ended questions to gather detailed information.

• Chief Complaint: "I've had a sore throat and a runny nose for three days."
• History of Present Illness: The patient reports a gradual onset of symptoms over the past three days, starting with a scratchy throat, followed by nasal congestion and clear rhinorrhea. No fever reported. Symptoms worsen at night.
• Past Medical History: No history of asthma or allergies. No recent travel or sick contacts.
• Medications: Over-the-counter cold medicine taken as needed.
• Allergies: No known drug allergies.

What do you include in the Objective section?

The Objective section covers your clinical findings from the physical exam and any relevant tests.

• Vital Signs: Temperature 98.6°F, Heart Rate 76 bpm, Respiratory Rate 18 breaths/min, Blood Pressure 120/80 mmHg.
• General Appearance: The patient appears mildly uncomfortable but in no acute distress.
• HEENT: Erythematous pharynx, no exudate. Nasal mucosa swollen with clear discharge. Tympanic membranes clear.
• Lungs: Clear to auscultation bilaterally.

How do you write the Assessment for a URI?

In the Assessment section, provide your clinical diagnosis based on the information gathered.

• Diagnosis: Upper respiratory infection, likely viral.

What's included in the Plan section?

The Plan outlines your management strategy and any follow-up needed.

• Treatment: Recommend symptomatic treatment with increased fluid intake, rest, and over-the-counter decongestants as needed. Advise against antibiotics unless symptoms worsen or persist beyond 10 days.
• Patient Education: Discuss the viral nature of the illness and expected course of recovery.
• Follow-up: Return if symptoms worsen or new symptoms develop, such as high fever or chest pain.