Martin reports that the depressive symptoms continue to worsen for him. That's why we've taken the time to collate some examples and SOAP note templates we think will help you to write more detailed and concise SOAP notes. Plan (P): The actions that the client and the practitioner have agreed upon to be taken due to the clinician's assessment of the client's current status, such as assessments, follow-up activities, referrals, and changes in the treatment. Family History: Mother died from congestive heart failure. Fred stated that it had been about one month since his last treatment. Mr. S is retired and lives with his 56 years old wife who runs a, grocery store and 28 years old daughter. Rationale: Patient had 2 separate instances of elevated NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. Martin denies any hallucinations, delusions, or other psychotic-related symptomatology. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash. Skin: Normal, no rashes, no lesions noted. It is not well-controlled since blood pressure is above the goal of 135/85. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. After starting medications, the target blood pressure for patients younger than 65 years should be 140/90 for the first three months, followed by 130/80. bilaterally, no drainage noted. Rivkin A. Blood Pressure f/u Nurse note 1 - The SOAPnote Project Santiago LM, Neto I. From taking a yoga class together to hosting a game night, these activities will help you take care of yourself. Denies fever, chills, or night However, an unintended consequence of electronic documentation is the ability to incorporate large volumes of data easily. SOAP notes for Hyperlipidaemia 5. He exhibits speech that is normal in rate, volume and articulation is coherent and spontaneous. Symptoms are what the patient describes and should be included in the subjective section whereas signs refer to quantifiable measurements that you have gathered indicating the presence of the CC.