SOAP_NoteTemplate.docx - S.O.A.P Note Template CASE ID...

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S.O.A.P. Note Template CASE ID# ____________________________ S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(eg. headache) Headache, sinus pressure and pain, abnormal smell from sinuses, and per patient, “I think I have a sinus infection” History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Pt. is a pleasant Caucasian woman who is her own historian. She presents to the office with complaints of headache, sinus pressure and pain with abnormal smell from sinuses, stating, “I believe I have a sinus infection”. Symptoms have an onset of 2 weeks ago and have been present since. She reports having chronic sinus infections every 6 months with last one being 3 months ago. She does report this sinus infection feels the same as others though the ear issues are different. She reports did see ENT and had Nasal polyps removed 5 years ago and had been received steroid injections from ENT for preventative measures but quit going back. She reports headache rated as terrible, along with frontal/ maxillary sinus pain and pressure stating “feels like I’ve been punched in the face along with abnormal foul smell from sinuses,

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