SOAP Charting
Your assignment is to include the list below and put the items
in a SOAP format. You will want to research to find a form of your
choice. You may add words to make sentences out of some of these
items. When you get done, you should be able to view the notes and
have a picture of this patient and know the next steps. Make sure
that you have the needed information from your research of SOAP
notes.
John Smith, DOB 08-10-1951 came into the clinic to see Dr.
Jerry Jones. Below are notes taken during Mr. Smith’s visit.
Blood Pressure: 165/85
Patient complains of left arm pain.
Complains of leg weakness and increases with going up
steps
Diagnosis: Hypertension, bilateral edema legs, and ankles,
Heart Disease, Diabetes
Elevate legs for 1 hour 4 times a day
Height: 182 cm
Inflammation on both lower legs
Pain is aching
Pain is better when I elevate my legs
Pain is worse at night
Peripheral edema, both ankles
Prescribe Hydrochlorothiazide, 25 mg tablet, 1 per day in the
am.
Pulse Oximetry: 97%
Pulse: 60 bpm
Rate pain 5 out of 10
Respiration: 16 bpm
Return for follow-up in two weeks
Temperature: 98.5
Wear support stockings till next appointment
Weight: 165 kg
X-rays show no fractures
SOAP Charting Your assignment is to include the list below and put the items in a SOAP format. You will want to researc
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