Primary Care Soap Note

SOAP Note

Prepared by: Elizabeth J. McKoy

Date: March 17, 2050

This document provides a detailed SOAP Note for Olivia Garcia, a 31-year-old female patient. The SOAP Note is an essential tool for clinical assessments, capturing patient's subjective and objective medical information, a diagnosis or assessment, and a treatment plan.

Component

Details

Subjective

  • Patient Name: Olivia Garcia

  • Age: 31 years

  • Gender: Female

  • Height: 5'5"

  • Weight: 140 lbs

O (Objective

  • Patient appears alert and oriented

  • Has no visible signs of distress

  • Normal vital signs

  • No notable abnormal physical findings

Assessment

The patient's current medical condition appears to be stable based on the present physical examination and history obtained. Since there are no immediate medical concerns identified, a routine follow-up is recommended.

Plan

  • Schedule next routine health check-up in six months

  • Continue with healthy lifestyle practices

  • Consider routine lab work for next visit to monitor overall health

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