SOAP Note
Created by
Grace Wong
Specialty
Family Medicine Specialist
Last edited
10/20/2026
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0 times
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About this template
A concise structure for documenting family medicine encounters in Subjective, Objective, Assessment, and Plan sections. It organizes reported concerns, findings, diagnoses, and care plans while including only information explicitly present in the provided material.
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Subjective
- 34yo F (Sarah Jenkins, DOB: 12/05/1990, PHN: 9876-543-210) presents at 10:15 with 3d hx of dysuria, urinary frequency, and suprapubic discomfort. Denies hematuria, fever, chills, flank pain, nausea/vomiting, or vaginal discharge/pruritus. LMP 28/10/2024, regular cycles, no pregnancy risk.
- PMHx: Mild intermittent asthma. PSHx: Laparoscopic appendectomy (2015).
- Meds: salbutamol (Ventolin) 100 mcg INH PRN; St. John's Wort 300 mg PO daily.
- SHx: Non-smoker, EtOH 2-3 drinks/wk, works as an accountant, sexually active with 1 male partner (uses barrier contraception).
- Allergies: Penicillin (urticaria).
Objective
- BP 116/74 mmHg, HR 72 bpm, Temp 36.8 °C, RR 14/min, SpO2 99% RA.
- Gen: Alert, NAD. Abdomen: Soft, mild suprapubic tenderness to deep palpation, no guarding or rebound. Back: Negative CVA tenderness bilaterally.
- Point-of-care urine dipstick: Leukocytes 3+, Nitrites positive, Blood trace, Protein negative, Glucose negative. Urine hCG: Negative.
Assessment
- Uncomplicated acute cystitis (UTI).
- Clinically stable with no signs of pyelonephritis or systemic infection.
Plan
- Start nitrofurantoin (MacroBID) 100 mg PO BID x 5d. Sent urine for C&S to guide therapy if no improvement. F/u in clinic in 1 wk PRN if symptoms persist.
- Advised to increase PO fluid intake, void post-intercourse, and use phenazopyridine (Pyridium) 200 mg PO TID PRN x 2d for dysuria. Counselled on ER return precautions (fever, rigors, flank pain, emesis). Discussed potential drug interactions with St. John's Wort.
- Referred to community pharmacist for comprehensive medication review regarding herbal supplement use.
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