SOAP Note

Please be sure to complete the SOAP note by following the grading rubric below in eLearn.

Although it is necessary to perform and document a comprehensive history and physical examination (H&P) at the beginning of the patientprovider relationship, it is unnecessary and too time consuming to document that level of detail at subsequent visits.

When such visits occur, visits are problem focused, either for monitoring of chronic conditions or for evaluation of a new problem. During a focused exam, you need to examine specifically the body part or system directly involved with the medical problem. One way to document problem-focused visits is with a SOAP note.

SOAP stands for Subjective, Objective, Assessment, and Plan. It is important to understand that sections of the SOAP note are interrelated. The completeness and accuracy of the history (subjective information) will help guide what you look for when performing a problem-specific physical examination (objective information) and formulating a list of possible causes, also known as differential diagnoses (DDX). Together, the subjective and objective information should lead you to, and should support, the assessment or most likely diagnosis. Once you have made an assessment, you can establish a plan of care.

Directions

This assignment utilizes a “Mock” patient. For any section of the SOAP Note that information is not provided for you, you must develop and document details that would support the diagnosis and plan for the patient.

SOAP Note:

1. Complete a SOAP note on a “mock” HEENT patient utilizing the SOAP Note Template. Please be sure to complete the SOAP Note in accordance with the “SOAP Note Grading Rubric” (Typed in Microsoft Word). Upload the completed SOAP template in Microsoft Word format. Complete the SOAP note on the following patient case below:

Patient Profile:

• Name: Mr. Jacob Whitman
• Age: 32
• Gender: Male
• Date of Presentation: 2.6.2026
• Clinical Setting: Adult Outpatient Clinic

Presenting Symptoms:

• 1. Severe left ear pain and tenderness
• 2. Swelling and redness behind the affected ear
• 3. Discharge from the affected ear (otorrhea)
• 4. Low-grade fever
• 5. Hearing loss or muffled hearing

Assessment Findings:

Upon examination, the nurse practitioner notes the following:

Vital Signs:

• Blood pressure: 112/64 mmHg
• Heart rate: 100 beats per minute
• Respiratory rate: 18 breaths per minute
• Temperature: 38.5C (101.3F)
• Pain: 8/10
• Height: 73″
• Weight: 201 lbs

Ear Assessment:

• Inflamed and swollen ear canal
• Tenderness and pain upon palpation of the mastoid area behind the affected ear
• Purulent discharge from the ear canal

Otoscopic Examination:

• Bulging and erythematous tympanic membrane on the affected side
• Loss of visible landmarks due to inflammation

Hearing Assessment:

• Conductive hearing loss reported by the patient and confirmed through whisper or tuning fork tests

Due Date

The SOAP Note is due by at 11:59 PM EST, at the end of Week 5.