Blank Soap Note
SOAP Note
Prepared by: Lisa G. Hundley, Eco Nest Enterprises
Date: January 2, 2050
This SOAP Note provides a summary of the medical evaluation of Michael Brown, a 35-year-old male. The note uses the SOAP (Subjective, Objective, Assessment, and Plan) format, providing a systematic technique for healthcare professionals to organize and document patient information, and guiding patient care.
|
S |
Subjective |
|---|---|
|
S1 |
Patient reports feeling consistently tired in the last several weeks |
|
S2 |
Complains of difficulty in concentrating |
|
S3 |
Denies any recent incidents or injuries |
|
O |
Objective |
|
O1 |
Blood pressure: 130/85 |
|
O2 |
Weight: 170lbs |
|
O3 |
Height: 5'10'' |
|
A |
Assessment |
|
A1 |
Potential stress-related issues or sleep disorder based on symptoms |
|
A2 |
No signs of physical injury or illness |
|
A3 |
General health seems good based on objective data |
|
P |
Plan |
|
P1 |
Recommend patient to keep a sleep journal to monitor patterns |
|
P2 |
Consider referral to a sleep specialist if symptoms persist |
|
P3 |
Advise reducing stress, improving diet and exercise routine |
