SOAP Note Example for Upper Respiratory Infection

What should you include in the Subjective section?

In the Subjective section, capture what the patient tells you about their symptoms. This might include:

• Chief complaint: "I've had a sore throat and stuffy nose for three days."
• History of present illness: "Symptoms started three days ago with a scratchy throat, followed by nasal congestion and mild cough. No fever reported."
• Past medical history: "No chronic illnesses, no previous similar episodes."
• Medications: "Taking over-the-counter cold medicine."
• Allergies: "No known drug allergies."

What goes in the Objective section?

The Objective section is where you document your findings from the physical exam and any tests. Include:

• Vital signs: "Temperature 98.6°F, heart rate 78 bpm, blood pressure 120/80 mmHg."
• Physical exam: "Nasal mucosa swollen, throat red with no exudate, lungs clear on auscultation."
• Other observations: "No lymphadenopathy, no rash."

How do you write the Assessment section?

In the Assessment section, provide your clinical judgment. This is where you diagnose the problem:

• Diagnosis: "Upper respiratory infection, likely viral."
• Differential diagnosis: "Consider allergic rhinitis or early sinusitis if symptoms persist."

What should the Plan section include?

The Plan section outlines your treatment strategy and follow-up. This might include:

• Medications: "Recommend continued use of over-the-counter cold medicine as needed."
• Patient education: "Advise rest, hydration, and monitoring for any worsening symptoms."
• Follow-up: "Return if symptoms worsen or do not improve in 7 days."

By organizing your notes in this way, you ensure that all critical information is captured and easily accessible. It also helps you track the patient's progress over time.