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Dr. Hello Soap Notes Template

hello rache soap

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361 views2 pages

Dr. Hello Soap Notes Template

hello rache soap

Uploaded by

jaysonadangalawschool
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SUBJECTIVE

HPI-ROS:

The patient is here for…

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

PLAN

1.
2.

A total encounter visit time includes pre-visit preparation, record review, timely documentation
of encounter, ordering medications/tests, communication with the care team if indicated, and
care coordination. Throughout the visit and at the conclusion of the encounter, the patient was
given ample opportunity to ask questions and obtain clarifying details. The patient verbalized
satisfaction with the responses and the information I provided. The patient will notify me if any
questions or concerns arise prior to their next scheduled visit with me.

I, Hello Rache, DO, personally performed the services described in this documentation, as
scribed by _, in my presence, and it is both accurate and complete.

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