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NR509 Sample SOAP Notes

NR509 Sample SOAP Notes

NR509 Sample SOAP Notes – Reason for visit: 24-year old HIV-infected woman here for visit 3 of HPTN ARV.

 

S: Client reports that the “rash” in her mouth noted at the last visit got better with the treatment (nystatin troches) and that she completed all doses. She has no complaints today. She reports that she has not missed any doses of her study medications (Combivir and NVP). She denies any rash, headache or tingling of her extremities. She states her appetite is good. Informed client that her CD4 counts from the last visit have continued to increase and are now 265. She expressed happiness at this news.

 

O: T: 37 C (by mouth); BP: 110/60; P: 64; R: 12; wt: 54.5 kg

Thin but well nourished appearing woman.

Skin: No rashes noted

HEENT: Oral mucosa pink, moist; no exudate

Lymph: Palpable nontender cervical, axillary and inguinal lymph nodes

Cardiac: Rhythm regular; no murmurs

Pulmonary: No rales, rhonchi, wheezing.

Abdominal: No hepatomegaly; spleen is nontender and palpable 4 cm below left costal margin.

GU: Not done.

Neuro: Gait normal. Oriented to person, place and time.

 

A: 24-year old HIV-infected woman doing well on protocol ARVS with an increase in CD4 count and a .5 kg weight gain since the last visit. Oral thrush noted at last visit resolved with 5-day course of nystatin troches. Generalized adenopathy and splenomegaly are unchanged from previous exams.

 

P: 1. Study-specific labs: CBC with differential and LFTs

  1. I month course of study drugs dispensed: combivir (150 mg lamivudine; 300 mg zidovudine), 1 tab morning and night, 66 dispensed; NVP (200 mg), 1 tab morning and night; 66 dispensed.
  2. Return for visit 4 for on March 1.
  3. Client also reminded to contact or return to the clinic is she has any problems before then.

 

The HIV Prevention Trials Network. (2008). Guidelines and examples on the soap format for chart notes. Retrieved from http://www.hptn.org/web%20documents/HPTNMOP/Appendices/Appendix2.pdf

NR509 Sample SOAP Notes

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