Free Sample Soap Note

Prepared by: [Your Name]

I. Subjective

A. Chief Complaint (CC)

The patient reports lower back pain for the past three weeks.

B. History of Present Illness (HPI)

The patient describes the pain as a dull ache in the lower back, aggravated by prolonged sitting and bending. Pain improves with over-the-counter pain medication but returns after a few hours. No radiation to the legs.

C. Review of Systems (ROS)

• Musculoskeletal: No joint swelling or stiffness.

• Neurological: No numbness or tingling.

• Cardiovascular: No chest pain or shortness of breath.

D. Past Medical History (PMH)

• Hypertension is controlled with medication.

E. Medications

• Lisinopril 10 mg daily.

F. Allergies

• No known drug allergies.

G. Family History

• Father with osteoarthritis.

H. Social History

• Non-smoker, occasional alcohol use, sedentary job.

II. Objective

A. Vital Signs

B. Physical Exam

III. Assessment

A. Primary Diagnosis

• Mechanical lower back pain.

B. Differential Diagnosis

• Lumbar strain or degenerative disc disease.

IV. Plan

A. Treatment

• Recommend ibuprofen 400 mg every 6 hours as needed.

B. Follow-Up

• Return in 2 weeks to assess progress.

C. Referrals

• Physical therapy evaluation.

D. Patient Education

• Advise posture correction and stretching exercises.

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