Family Medicine SOAP Note Sample #1
SUBJECTIVE: The patient is here today with a lesion on her right cheek. This was previously removed with shave biopsy, which showed a basal cell carcinoma, nodular-type. She is now here for complete excision.
The patient is also here today to follow up on her hypertension. She notes no difficulties with headaches, nosebleeds or chest pain. The patient has become quite deconditioned and has more significant dyspnea with exertion but no associated chest pain.
OBJECTIVE: Blood pressure is 132/82. Pulse oximetry is 98% on room air. There is a cystic-appearing lesion on the right cheek.
After appropriate identification of the correct patient and site, a time-out was taken. Again, the appropriate patient and site were identified and a final time-out was taken. The lesion was anesthetized with 2% Xylocaine with epinephrine and prepped with triple Betadine. Using sterile technique, the lesion was removed with elliptical excision down to the subcutaneous tissue. The wound was then approximated with a 5-0 nylon running suture, bacitracin, and Band-Aid was applied.
ASSESSMENT: Basal cell carcinoma, nodular-type, removed from the right cheek.
PLAN: The patient was given wound instructions. We will follow up with her as she is home bound in the next 24 hours to assess the wound and lesion. She will follow up in 5 to 7 days for suture removal.
Family Medicine SOAP Note Sample #2
REASON FOR VISIT: Lesion, pigmented, over the left cheek.
SUBJECTIVE: The patient presents to the office concerned about the treatment on the left cheek. She had a tiny mole on the cheek for many years. For the last six months, she has noticed that the lesion has been increasing in size. She denies any discomfort or any crusting or any bleeding at that side.
OBJECTIVE: On examination, blood pressure 142/66. On examination of the face, over the left cheek, she has hyperpigmented patchy irregular lesion, which is flat, not indurated without any indurations or any superficial skin changes.
ASSESSMENT AND PLAN: Left cheek mole, appears benign, but the patient wants to see Dr. (XX) and a referral to Dr. (XX) will be done at the patient’s request for further evaluation and possible biopsy, if needed, due to the recent change in the lesion.
Family Medicine SOAP Note Sample #3
SUBJECTIVE: The patient is complaining of some discomfort on the underside of her left breast and says there was some drainage from there yesterday. She did have problems with some cellulitis in that area last May, but it had completely cleared. No history of trauma or breaks in the skin. She is concerned in that her paternal aunt had breast cancer and died at the age 41. Her mother and maternal aunts have had no problems.
OBJECTIVE: Blood pressure 122/72, pulse 98 and regular, weight 220, temperature 97.8. Left breast shows an area of erythema measuring about 2 cm in diameter with some slight induration beneath it. Just inferior to that is a small purplish area measuring 4-5 mm in diameter, but this is nontender. There are no visible breaks in the skin and no apparent drainage.
ASSESSMENT: Small area of cellulitis.
PLAN: Keflex 500 mg b.i.d. x5 days. Warm compresses t.i.d. We told to call if it is not completely better by then or if there is any worsening in the next few days.
Family Medicine SOAP Note Sample #4
SUBJECTIVE: The patient is here today with a 24-hour history of right ear pain. She has noted that her ear canal is somewhat itchy. She tried using some drops; however, she continues to have discomfort. She has had no upper respiratory symptoms. She has noted some mild swelling anterior to the right ear. She does have a toothache but it is not necessarily bothering her ear. She notes no sore throat or fever.
OBJECTIVE: HEENT: There is some preauricular swelling on the right. Right ear canal is narrowed, swollen, erythematous, and tender on insertion of the speculum. Left tympanic membrane is normal. Oropharynx: Clear. Neck is supple without adenopathy.
ASSESSMENT: Otitis externa.
PLAN: The patient is given Cipro 500 mg 1 b.i.d. for 10 days. She is given Cortisporin Otic drops to use 3 drops to the right ear 3-4 times a day. She will follow up p.r.n. no improvement.
Family Medicine SOAP Note Sample #5
SUBJECTIVE: The patient noted a tick bite which occurred on the right leg, just below the knee. She removed the tick and brought it with her. She is concerned, however, because there is a remnant of the tick still left in the skin.
OBJECTIVE: The tick is a deer tick. There is an erythematous papule on the right shin with foreign body centrally. The area is wiped clean with alcohol and using a #11 blade, the remnants of the tick are removed from the wound. The wound is covered with bacitracin, Band-Aid.
ASSESSMENT: Tick bite, less than 24 hours.
PLAN: The patient is given doxycycline 100 mg 2 tablets to take it once. She will follow up if she develops flu-like symptoms and will return in 6 weeks for a Lyme titer.
