SOAP Note Example NP – Best 3 Examples

SOAP Note Example NP – Pediatric Patient

S: Subjective

Chief Complaint: “My daughter has had ear pain and fever for two days.” (Parent report)
HPI:

• 5-year-old female with 2-day history of right ear pain, described as “sharp,” rated 6/10.
• Associated symptoms: Fever (max 101.3°F), fussiness, difficulty sleeping, and decreased appetite.
• Tugging at right ear. No vomiting, diarrhea, or cough.
• Recent upper respiratory infection (URI) resolved 1 week ago.
  PMH: Full-term birth, no chronic illnesses.
  Immunizations: Up to date, including PCV13 and influenza.
  Allergies: NKDA.
  Family History: No history of recurrent ear infections.
  Social: Lives with parents and siblings; attends preschool.

O: Objective

Vital Signs:

• Temp: 101.3°F (oral)
• HR: 110 bpm
• RR: 22/min
• SpO2: 98% RA
• Weight: 18 kg (50th percentile)

Physical Exam:

• General: Alert but fussy.
• HEENT:
  • Right ear: Tympanic membrane erythematous, bulging, loss of landmarks, decreased mobility on pneumatic otoscopy.
  • Left ear: Normal.
  • Throat: Mild erythema, no exudate.
  • Nose: Clear, no discharge.
• Neck: No lymphadenopathy.
• Lungs: Clear bilaterally, no wheezing.
• Skin: No rash.

A: Assessment

Primary Diagnosis:

• Acute Otitis Media (AOM), Right Ear (ICD-10: H66.91)
  • Rationale:
    • Clinical findings: Bulging, erythematous TM with decreased mobility (key diagnostic criteria for AOM).
    • Supportive symptoms: Acute onset ear pain, fever, recent URI.

Differential Diagnoses:

1. Otitis Externa (ICD-10: H60.90)
   • Rationale for Exclusion: Absence of ear canal edema, pain on tragus palpation, or history of swimming.
2. Viral Pharyngitis (ICD-10: J02.9)
   • Rationale for Exclusion: Mild throat erythema without exudate or tonsillar swelling; primary symptom is ear pain.
3. Teething (ICD-10: K00.7)
   • Rationale for Exclusion: Fever >100.4°F and ear findings inconsistent with teething.

P: Plan

1. Antibiotic Therapy:
   • Amoxicillin 45 mg/kg/day divided BID x10 days (18 kg → 405 mg BID).
   • Rationale: First-line treatment for AOM in patients without penicillin allergy. High-dose amoxicillin covers S. pneumoniae and H. influenzae.
2. Symptom Management:
   • Ibuprofen 10 mg/kg every 6–8 hours PRN pain/fever.
   • Acetaminophen 15 mg/kg every 4–6 hours PRN (if ibuprofen contraindicated).
3. Follow-Up:
   • Re-evaluate in 10 days to confirm resolution.
   • Return immediately if fever persists >48 hours, worsening pain, or hearing loss.
4. Parent Education:
   • Counsel on completing antibiotics even if symptoms improve.
   • Avoid bottle propping to reduce aspiration risk.
   • Use analgesics as needed for comfort.
5. Prevention:
   • Encourage hand hygiene and avoid sick contacts.

Rationale for ICD-10 Selection:

• H66.91: Specific to right ear AOM (laterality improves coding accuracy).
• Differentials excluded based on history/exam findings to avoid misclassification.

Clinical Decision-Making:

• AOM diagnosis aligns with AAP criteria (acute symptoms + middle ear effusion). Immediate antibiotics chosen due to age <6 years, bilateral symptoms excluded, and significant discomfort.

Example SOAP Note Nurse Practitioners – Teen Patient

SUBJECTIVE:

Chief Complaint:

“I’ve been feeling really sad and tired all the time for the past 3 months”

History of Present Illness: Alex is a 16-year-old male who presents with mother for evaluation of persistent sadness, fatigue, and academic decline over the past 3 months. Patient reports feeling sad “most of the day, almost every day,” with decreased interest in basketball and video games, which he previously enjoyed. Reports difficulty falling asleep and staying asleep, waking early at 4-5 AM unable to return to sleep. Has experienced a 10-pound unintentional weight loss over the past 2 months. Describes feeling “worthless” and has trouble concentrating on schoolwork. Denies suicidal ideation, plan, or intent. No prior history of self-harm. No manic episodes.

Past Medical History: No significant medical history
Past Psychiatric History: None
Medications: None
Allergies: NKDA
Family History: Mother with history of depression and anxiety; maternal grandmother with history of depression
Social History: Lives with mother and younger sister. Parents divorced 6 months ago. Changed schools 4 months ago due to move. Reports difficulty making new friends. Denies alcohol, tobacco, or substance use.
Review of Systems: Constitutional: Fatigue, weight loss. Psych: As above. All other systems negative.

OBJECTIVE:

Vital Signs:
BP 118/72, HR 78, RR 16, Temp 98.6°F, Ht 5’10”, Wt 155 lbs (down from 165 lbs 2 months ago)

Physical Examination:

• General: Alert, appropriately dressed adolescent male who appears stated age. Makes minimal eye contact. Psychomotor retardation noted.
• HEENT: Normocephalic, atraumatic. No thyromegaly.
• Cardiovascular: Regular rate and rhythm, no murmurs
• Respiratory: Clear to auscultation bilaterally
• Abdominal: Soft, non-tender, no organomegaly
• Neurological: CN II-XII intact, no focal deficits
• Psychiatric: Affect flat, mood depressed. Speech slow in rate and volume. Thought process linear. No evidence of hallucinations or delusions. No suicidal or homicidal ideation. Oriented x3. Good insight and judgment.

PHQ-9 Score: 18 (Moderately severe depression)

Laboratory Results:

• TSH: 2.1 mIU/L (normal range: 0.4-4.0 mIU/L)
• CBC: Within normal limits
• Comprehensive Metabolic Panel: Within normal limits
• Urine drug screen: Negative

ASSESSMENT:

Primary Diagnosis:

• Major Depressive Disorder, single episode, moderate (F32.1)
  Rationale: Patient meets DSM-5 criteria with depressed mood, anhedonia, significant weight loss, insomnia, psychomotor retardation, fatigue, feelings of worthlessness, and diminished ability to concentrate for > 2 months. Symptoms are causing significant impairment in academic and social functioning. PHQ-9 score indicates moderately severe depression.

Differential Diagnoses:

1. Adjustment Disorder with Depressed Mood (F43.21)
   Rationale: Recent stressors include parental divorce and school change. However, symptom severity and duration exceed typical adjustment reaction.
2. Persistent Depressive Disorder (Dysthymia) (F34.1)
   Rationale: Symptoms have not persisted for ≥ 1 year as required for this diagnosis in adolescents.
3. Bipolar Disorder (F31.9)
   Rationale: No history of manic or hypomanic episodes.
4. Hypothyroidism (E03.9)
   Rationale: Some symptoms overlap, but normal TSH rules this out.
5. Substance-Induced Depressive Disorder (F19.94)
   Rationale: Negative drug screen and denial of substance use make this less likely.

PLAN:

Psychotherapy:

• Refer to adolescent therapist for Cognitive Behavioral Therapy (CBT), weekly sessions
• Rationale: Evidence-based first-line treatment for adolescent depression; helps address negative thought patterns and develop coping skills

Medication:

• Start Fluoxetine 10 mg PO daily for 1 week, then increase to 20 mg daily
• Rationale: FDA-approved SSRI for adolescent depression; start low and titrate slowly to minimize side effects
• Discussed black box warning regarding increased risk of suicidal thoughts/behaviors in adolescents
• Parent and patient educated on side effects, benefits, and risks

Safety Plan:

• Developed safety plan with patient and mother
• Provided crisis hotline numbers and local emergency resources
• Rationale: Essential component of depression management even in absence of current suicidal ideation

Monitoring:

• Follow-up in 1 week to assess for side effects and symptom changes
• Repeat PHQ-9 at each visit to track symptom improvement
• Rationale: Close monitoring needed during initiation of treatment, especially in adolescents

School Accommodations:

• Provided letter for school counselor recommending temporary accommodations
• Rationale: Support academic functioning during acute phase of illness

Family Support:

• Provided information on parent support groups and family therapy options
• Rationale: Family involvement improves outcomes in adolescent depression

Lifestyle Modifications:

• Encouraged regular exercise, sleep hygiene, and healthy eating
• Rationale: Adjunctive non-pharmacological interventions with evidence supporting efficacy in depression

Next Appointment: 1 week from today
Duration: 45 minutes

Nurse Practitioner SOAP Note Example – Major Depressive Disorder

Subjective:

CC (Chief Complaint):
45-year-old Caucasian female presents with complaints of persistent low mood, fatigue, and difficulty concentrating over the past six months. She reports feeling “overwhelmed and exhausted all the time,” with decreased interest in activities she used to enjoy.

HPI:

• Onset: Symptoms began approximately six months ago after experiencing increased work-related stress and the loss of a close family member.
• Duration: Symptoms have been persistent, occurring nearly every day.
• Character:
  • Depressed mood, frequent crying spells.
  • Difficulty sleeping, early morning awakening.
  • Feelings of worthlessness and guilt, especially about not being “productive enough.”
  • Increased fatigue despite adequate sleep.
  • Decreased motivation and enjoyment in hobbies.
  • Reports some unintentional weight loss (approximately 8 lbs in the past 3 months).
  • Concentration issues affecting job performance.
  • No suicidal ideation currently but states, “I feel like I don’t have a purpose anymore.”

Substance Current Use:

• Drinks 1-2 glasses of wine on weekends but denies excessive alcohol use.
• Smoked cigarettes in her 20s but quit 10 years ago.
• No history of illicit drug use.

Medical History:

• Current Medications: None
• Allergies: No known drug allergies
• Reproductive Hx: Menopausal symptoms started in the last year, with occasional hot flashes and night sweats.

ROS:

• GENERAL: Reports weight loss, fatigue.
• HEENT: No vision changes, no tinnitus.
• SKIN: No rashes, itching, or abnormal bruising.
• CARDIOVASCULAR: No chest pain, palpitations.
• RESPIRATORY: No shortness of breath or cough.
• GASTROINTESTINAL: Reports mild nausea, occasional loss of appetite.
• GENITOURINARY: No dysuria, normal urine output.
• NEUROLOGICAL: No dizziness, headaches, or focal deficits.
• MUSCULOSKELETAL: No joint pain or swelling.
• ENDOCRINOLOGIC: No excessive thirst or urination.

Objective:

Vital Signs:

• BP: 124/78 mmHg
• HR: 72 bpm
• RR: 16 bpm
• Temp: 98.2°F
• O2 Sat: 98% on room air
• BMI: 24.5 kg/m²

Mental Status Examination:

• Appearance: Well-groomed, appropriate attire for weather.
• Gait: Normal.
• Behavior: Cooperative, but appears tired and downcast.
• Eye Contact: Fair, intermittently downcast.
• Speech Rate & Tone: Soft, slow, but articulate.
• Mood: Depressed.
• Affect: Constricted, congruent with mood.
• Thought Process: Linear, logical.
• Thought Content: No delusions, no psychotic features.
• Suicide Ideation: Denies, but reports feelings of hopelessness.
• Homicidal Ideation: None.
• Perceptual Disturbances: None.
• Insight & Judgment: Fair.
• Fund of Knowledge: Appropriate.
• Cognition: Alert, oriented to person, place, and situation.

Diagnostic Results:

• PHQ-9 Score: 18 (Moderate-Severe Depression)
• TSH & T4: Pending (rule out hypothyroidism contribution).
• CMP: Pending (assess nutritional and metabolic status).

Assessment:

Primary Diagnosis:

🩺 F32.1 – Major Depressive Disorder, Single Episode, Moderate

• Rationale: Patient meets DSM-5 criteria for Major Depressive Disorder (MDD) with symptoms persisting for over 6 months, including depressed mood, anhedonia, fatigue, changes in sleep and appetite, difficulty concentrating, and feelings of worthlessness. The PHQ-9 score supports moderate to severe depression.

Differential Diagnoses:

1. F41.1 – Generalized Anxiety Disorder (GAD)
   • Patient reports excessive worry, fatigue, and difficulty concentrating, which overlap with GAD. However, her symptoms are primarily depressive, not excessive worry and fear.
2. E66.9 – Menopausal Symptoms with Mood Changes
   • Patient has started experiencing menopausal symptoms (hot flashes, night sweats). While menopause can contribute to mood instability, the duration and severity of symptoms suggest an independent depressive disorder.
3. F34.1 – Persistent Depressive Disorder (Dysthymia)
   • Dysthymia is diagnosed when symptoms persist for at least 2 years. This patient’s depressive symptoms have lasted six months, making Major Depressive Disorder the more appropriate diagnosis.
4. E03.9 – Hypothyroidism, Unspecified
   • Hypothyroidism can mimic depression (fatigue, weight changes, concentration issues). TSH and T4 testing is pending to rule this out.
5. F43.21 – Adjustment Disorder with Depressed Mood
   • This diagnosis is considered but ruled out because the patient’s symptoms are more pervasive and persistent than what is typically seen in adjustment disorder, which resolves within 6 months after a stressor.

Plan (Treatment & Rationale):

1. Pharmacologic Treatment:

• Start Sertraline (Zoloft) 50 mg PO daily
  • First-line SSRI for depression, low side effect profile, effective for moderate-severe MDD.
  • Patient educated on delayed onset of action (2-4 weeks for effect).
  • Side effects discussed (nausea, headache, sexual dysfunction).
  • Will follow up in 4 weeks to assess response and adjust dose if needed.

2. Psychotherapy Referral:

• Cognitive Behavioral Therapy (CBT) recommended
  • Proven effective in restructuring negative thoughts and improving coping mechanisms.
  • Encouraged patient to engage in therapy 1x/week.

3. Lifestyle & Holistic Interventions:

• Exercise: Encourage 30 minutes of moderate exercise (walking, yoga) 5x/week to help with mood.
• Sleep Hygiene: Maintain a consistent bedtime routine, avoid screens before bed.
• Mindfulness & Relaxation Techniques: Journaling, meditation, deep breathing exercises.

4. Nutritional Support:

• Increase omega-3 fatty acids (salmon, flaxseeds, walnuts) for brain health.
• Reduce caffeine/alcohol intake to improve sleep and anxiety symptoms.
• Ensure adequate hydration and balanced diet.

5. Lab Follow-Up:

• TSH/T4 Results Pending: If abnormal, consider endocrinology referral.
• CMP: Check for metabolic/nutritional deficiencies.

6. Follow-Up Plan:

• Follow-up in 4 weeks to assess medication response and side effects.
• Check PHQ-9 score for improvement.
• Assess sleep, appetite, and suicidal ideation.
• If no improvement in 6-8 weeks, consider increasing Sertraline dose or switching to an SNRI (e.g., Venlafaxine).

7. Safety & Crisis Planning:

• Patient educated on warning signs for worsening depression and suicidal thoughts.
• Crisis hotline provided: 988 Suicide & Crisis Lifeline.
• Patient instructed to seek immediate help if experiencing severe suicidal thoughts.