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10 Common Nurse Practitioner SOAP Note Examples

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List of cases

  1. Hypertension Management
  2. Type 2 Diabetes Follow-up
  3. Upper Respiratory Infection
  4. Asthma Exacerbation
  5. Urinary Tract Infection
  6. Migraine Headache
  7. Gastroesophageal Reflux Disease (GERD)
  8. Osteoarthritis Management
  9. Depression with Anxiety
  10. Annual Wellness Visit

1. Hypertension Management

Description

The patient presents for follow-up of hypertension with concerns about recent home blood pressure readings and medication side effects.

SOAP Note

Patient Name: Robert Johnson

Date of Visit: 09/01/2024

Subjective

Robert Johnson, a 58-year-old male, presents for scheduled follow-up of hypertension. He reports home blood pressure readings ranging from 145-160/85-95 mmHg over the past month, taken twice daily. Patient complains of occasional dizziness and ankle swelling since starting amlodipine 5mg daily one month ago. Denies chest pain, shortness of breath, headaches, or visual changes. Reports good medication compliance and following low-sodium diet. Exercise includes walking 30 minutes, 3 times weekly. Denies tobacco use, reports occasional alcohol use (1-2 drinks weekly).

Objective

  • Vital Signs:
    • BP: 152/88 mmHg (right arm, seated)
    • HR: 76 bpm, regular
    • RR: 16/min
    • Temp: 98.6°F
    • SpO2: 98% on room air
    • BMI: 28.4 kg/m²
  • Physical Examination:
    • General: Alert, well-appearing male in no acute distress
    • HEENT: Normocephalic, PERRLA, no AV nicking on fundoscopic exam
    • Cardiovascular: Regular rate and rhythm, no murmurs/gallops/rubs
    • Respiratory: Clear to auscultation bilaterally
    • Extremities: 1+ bilateral ankle edema
  • Recent Labs (2 weeks ago):
    • Basic Metabolic Panel: Within normal limits
    • eGFR: >60 mL/min
    • Lipid Panel: Total Cholesterol 195, LDL 110, HDL 45, TG 150

Assessment

  1. Essential Hypertension (ICD-10: I10)
    • Suboptimal control on current regimen
    • Medication side effects present (ankle edema)
    • No evidence of end-organ damage
  2. Overweight (ICD-10: E66.3)
    • Contributing to hypertension management challenges
  3. Medication side effects
    • Amlodipine-induced peripheral edema

Plan

  1. Medications:

    • Discontinue amlodipine 5mg daily
    • Start losartan 50mg daily
    • Continue current supplements

  2. Monitoring:

    • Continue home BP monitoring twice daily
    • Record readings in provided log
    • Return to clinic in 2 weeks for BP check

  3. Lifestyle Modifications:

    • Reinforce low-sodium diet (less than 2g/day)
    • Increase exercise to 30 minutes, 5 times weekly
    • Weight loss goal of 1-2 lbs per week

  4. Patient Education:

    • Review proper BP measurement technique
    • Discuss warning signs requiring immediate attention
    • Provide dietary counseling resources

  5. Follow-up:

    • BP check with nurse in 2 weeks
    • Full follow-up visit in 1 month
    • Call if symptoms worsen or BP >180/100

CPT Code: 99214 (Level 4 Established Patient Visit)

2. Type 2 Diabetes Follow-up

Description

The patient presents for routine follow-up of type 2 diabetes mellitus with recent blood glucose monitoring results and medication management.

SOAP Note

Patient Name: Maria Garcia

Date of Visit: 09/02/2024

Subjective

Maria Garcia, a 62-year-old female, presents for scheduled 3-month diabetes follow-up. She reports home blood glucose readings ranging from 130-180 mg/dL fasting and 150-200 mg/dL post-meals. Patient notes occasional episodes of hypoglycemia (lowest reading 65 mg/dL) in late afternoons. Reports good medication compliance with metformin 1000mg twice daily and glipizide 5mg daily. Following recommended diet but admits to occasional high-carb meals. Denies polyuria, polydipsia, or vision changes. Exercises by swimming twice weekly. Reports checking feet daily and no new lesions noted.

Objective

  • Vital Signs:
    • BP: 128/76 mmHg
    • HR: 72 bpm
    • RR: 16/min
    • Temp: 98.4°F
    • SpO2: 99% on room air
    • BMI: 31.2 kg/m²
  • Physical Examination:
    • General: Well-appearing female in no distress
    • HEENT: Normocephalic, PERRLA, no diabetic retinopathy
    • Cardiovascular: Regular rate and rhythm, no edema
    • Respiratory: Clear to auscultation
    • Skin: No lesions or ulcers
    • Feet: Normal sensation to monofilament testing, pulses 2+ bilaterally
  • Labs:
    • HbA1C: 7.8% (down from 8.3% 3 months ago)
    • Fasting Glucose: 142 mg/dL
    • Comprehensive Metabolic Panel: Within normal limits
    • Urine Microalbumin/Creatinine ratio: 25 mg/g

Assessment

  1. Type 2 Diabetes Mellitus (ICD-10: E11.9)
    • Improved but not at goal (HbA1C target less than 7%)
    • Experiencing occasional hypoglycemia
  2. Obesity (ICD-10: E66.01)
    • Contributing to diabetes management challenges
  3. Microalbuminuria (ICD-10: R80.9)
    • Early diabetic nephropathy

Plan

  1. Medications:

    • Continue metformin 1000mg twice daily
    • Decrease glipizide to 2.5mg daily due to hypoglycemic episodes
    • Continue ACE inhibitor for renal protection

  2. Monitoring:

    • Continue glucose monitoring 2-4 times daily
    • Record hypoglycemic episodes
    • Blood pressure monitoring weekly

  3. Lifestyle Modifications:

    • Review carbohydrate counting
    • Increase exercise to 3-4 times weekly
    • Weight loss goal of 5-10 lbs in 3 months

  4. Patient Education:

    • Review hypoglycemia management
    • Discuss importance of consistent meal timing
    • Reinforce foot care and skin inspection

  5. Preventive Care:

    • Schedule diabetic eye exam
    • Update pneumococcal vaccination
    • Schedule dental examination

  6. Follow-up:

    • Return in 3 months for HbA1C check
    • Earlier if hypoglycemia persists
    • Annual comprehensive diabetic exam due in 6 months

CPT Code: 99214 (Level 4 Established Patient Visit)

3. Upper Respiratory Infection

Description

The patient presents with symptoms of acute upper respiratory infection including congestion, cough, and sore throat.

SOAP Note

Patient Name: James Wilson

Date of Visit: 09/03/2024

Subjective

James Wilson, a 35-year-old male, presents with 4 days of nasal congestion, productive cough with yellow sputum, sore throat, and mild fever. Reports maximum temperature at home was 100.8°F. Symptoms began gradually with sore throat, followed by congestion and cough. Denies shortness of breath, chest pain, or ear pain. Has been using over-the-counter Tylenol and Mucinex with minimal relief. No known sick contacts. No history of asthma or chronic respiratory conditions. Up-to-date on vaccinations including flu shot. Denies smoking.

Objective

  • Vital Signs:
    • BP: 122/78 mmHg
    • HR: 82 bpm
    • RR: 16/min
    • Temp: 99.6°F
    • SpO2: 98% on room air
  • Physical Examination:
    • General: Alert, mild distress due to congestion
    • HEENT:
      • Nasal mucosa erythematous with clear discharge
      • Throat moderately erythematous without exudates
      • Tympanic membranes clear bilaterally
    • Neck: No lymphadenopathy
    • Respiratory: Clear breath sounds, no wheezing or rales
    • Cardiovascular: Regular rate and rhythm
  • Point of Care Testing:
    • Rapid Strep: Negative
    • COVID-19 Rapid Test: Negative

Assessment

  1. Acute Upper Respiratory Infection (ICD-10: J06.9)
    • Viral etiology most likely
    • Moderate symptoms without complications
    • No indication for antibiotics

Plan

  1. Medications:

    • Acetaminophen 650mg every 6 hours as needed for fever/pain
    • Guaifenesin 600mg every 12 hours for cough
    • Saline nasal spray as needed

  2. Supportive Care:

    • Rest and adequate hydration
    • Humidifier use at night
    • Salt water gargles for sore throat

  3. Patient Education:

    • Expected course of illness (7-10 days)
    • Viral nature of infection
    • Hand hygiene and prevention measures

  4. Return Precautions:

    • Return if symptoms worsen
    • Watch for warning signs:
      • Difficulty breathing
      • High fever >102°F
      • Severe headache or neck stiffness

  5. Follow-up:

    • As needed if symptoms persist beyond 10 days
    • Consider telehealth check in 5 days if not improving

CPT Code: 99213 (Level 3 Established Patient Visit)

4. Asthma Exacerbation

Description

The patient presents with worsening asthma symptoms including increased shortness of breath, wheezing, and cough over the past 48 hours.

SOAP Note

Patient Name: Sarah Thompson

Date of Visit: 09/04/2024

Subjective

Sarah Thompson, a 28-year-old female, presents with worsening asthma symptoms over the past 48 hours. Reports increased shortness of breath, wheezing, and nonproductive cough, especially at night and early morning. Using albuterol inhaler every 4 hours with only temporary relief. Symptoms began after exposure to cat at friend's house. Reports peak flow readings at home decreased from baseline of 400 to current 250. Denies fever, chest pain, or respiratory infection symptoms. History of well-controlled asthma on maintenance inhaler (fluticasone/salmeterol). No recent oral steroid use or ER visits.

Objective

  • Vital Signs:
    • BP: 128/82 mmHg
    • HR: 98 bpm
    • RR: 24/min
    • Temp: 98.6°F
    • SpO2: 94% on room air
  • Physical Examination:
    • General: Mild respiratory distress, speaking in short sentences
    • HEENT: Normal
    • Respiratory:
      • Bilateral expiratory wheezing
      • Prolonged expiratory phase
      • No accessory muscle use
    • Cardiovascular: Tachycardic, regular rhythm
  • Peak Flow: 260 L/min (65% of personal best)
  • Pulse Oximetry: Improves to 97% with albuterol treatment

Assessment

  1. Acute Asthma Exacerbation (ICD-10: J45.901)
    • Moderate severity
    • Triggered by pet allergen exposure
    • Partially responsive to bronchodilators
  2. Allergic Asthma (ICD-10: J45.909)
    • Known pet dander trigger
    • Otherwise well-controlled on maintenance therapy

Plan

  1. Immediate Treatment:

    • Albuterol nebulizer treatment 2.5mg/3mL in office
    • Oral prednisone 40mg daily for 5 days

  2. Medications:

    • Continue fluticasone/salmeterol inhaler as prescribed
    • Increase albuterol MDI frequency as needed
    • Add oral prednisone burst

  3. Monitoring:

    • Continue peak flow monitoring 2-3 times daily
    • Record symptom frequency and rescue inhaler use
    • Follow up in 1 week or sooner if not improving

  4. Patient Education:

    • Review proper inhaler technique
    • Discuss asthma action plan
    • Avoid known triggers
    • When to seek emergency care

  5. Follow-up:

    • Return to clinic in 1 week
    • Earlier if symptoms worsen
    • Consider allergist referral

CPT Code: 99214 (Level 4 Established Patient Visit)

5. Urinary Tract Infection

Description

The patient presents with symptoms of urinary tract infection including dysuria, frequency, and urgency.

SOAP Note

Patient Name: Emily Chen

Date of Visit: 09/05/2024

Subjective

Emily Chen, a 45-year-old female, presents with 3 days of urinary symptoms including burning with urination, increased frequency, and urgency. Reports urinating every 1-2 hours during the day and 3-4 times at night. Denies fever, back pain, or vaginal discharge. No history of recent sexual activity or changes in partners. Reports adequate fluid intake. No history of recurrent UTIs. Last UTI was 2 years ago. No known drug allergies.

Objective

  • Vital Signs:
    • BP: 118/72 mmHg
    • HR: 76 bpm
    • RR: 16/min
    • Temp: 98.8°F
  • Physical Examination:
    • General: Well-appearing female in no acute distress
    • Abdomen:
      • Soft, non-tender
      • No suprapubic or CVA tenderness
    • External Genitalia: Normal appearance, no discharge
  • Point of Care Testing:
    • Urinalysis:
      • Leukocyte esterase: Positive
      • Nitrites: Positive
      • WBC: >20/hpf
      • RBC: 5-10/hpf
      • Bacteria: Moderate

Assessment

  1. Acute Uncomplicated Urinary Tract Infection (ICD-10: N39.0)
    • Classic symptoms
    • Positive urinalysis findings
    • No signs of upper tract involvement

Plan

  1. Medications:

    • Nitrofurantoin 100mg twice daily for 5 days
    • Consider phenazopyridine 200mg three times daily for 2 days for symptom relief

  2. Hydration:

    • Increase fluid intake to 2-3 liters daily
    • Void frequently and completely

  3. Patient Education:

    • Complete entire course of antibiotics
    • UTI prevention strategies
    • Warning signs of pyelonephritis

  4. Return Precautions:

    • Return if symptoms worsen or persist
    • Watch for:
      • Fever >101°F
      • Back pain
      • Severe abdominal pain

  5. Follow-up:

    • As needed if symptoms persist
    • Consider urine culture if recurrence within 3 months

CPT Code: 99213 (Level 3 Established Patient Visit)

6. Migraine Headache

Description

The patient presents with acute migraine headache accompanied by photophobia, nausea, and visual aura.

SOAP Note

Patient Name: Lisa Anderson

Date of Visit: 09/06/2024

Subjective

Lisa Anderson, a 32-year-old female, presents with severe migraine headache that began 12 hours ago. Reports typical visual aura with zigzag lines preceding headache onset. Describes throbbing right-sided head pain, rated 8/10, with associated photophobia, phonophobia, and nausea. Has taken sumatriptan 100mg with minimal relief. Reports increased frequency of migraines over past month (4 episodes vs. usual 1-2). Identifies stress and irregular sleep as possible triggers. No recent head trauma or new medications. Known history of migraines for 10 years.

Objective

  • Vital Signs:
    • BP: 126/78 mmHg
    • HR: 82 bpm
    • RR: 16/min
    • Temp: 98.4°F
  • Physical Examination:
    • General: Moderate distress, photophobic
    • HEENT:
      • PERRLA
      • No papilledema
      • Normal fundoscopic exam
    • Neck: Supple, mild right-sided muscle tension
    • Neurological:
      • Cranial nerves intact
      • No focal deficits
      • Normal strength and sensation

Assessment

  1. Migraine with Aura (ICD-10: G43.109)
    • Acute episode with typical features
    • Incomplete response to abortive therapy
    • Increased frequency noted
  2. Medication Overuse Concern
    • Using sumatriptan >2 times weekly
  3. Stress-related Factors
    • Contributing to increased frequency

Plan

  1. Acute Treatment:

    • Ketorolac 30mg IM injection
    • Promethazine 25mg IM for nausea
    • IV fluids if needed

  2. Medications:

    • Prescribe rizatriptan 10mg as alternative abortive
    • Consider prophylactic therapy given increased frequency
    • Limit acute medications to less than 2 days/week

  3. Lifestyle Modifications:

    • Maintain regular sleep schedule
    • Identify and avoid triggers
    • Stress management techniques

  4. Patient Education:

    • Migraine diary documentation
    • Medication overuse risk
    • Lifestyle trigger management

  5. Follow-up:

    • Return in 2 weeks for preventive medication discussion
    • Keep headache diary until next visit
    • Earlier if symptoms worsen

CPT Code: 99214 (Level 4 Established Patient Visit)

7. Gastroesophageal Reflux Disease (GERD)

Description

The patient presents for follow-up of GERD symptoms with concerns about medication effectiveness and dietary triggers.

SOAP Note

Patient Name: Michael Brown

Date of Visit: 09/07/2024

Subjective

Michael Brown, a 52-year-old male, presents for follow-up of GERD symptoms. Reports partial improvement with omeprazole 20mg daily but still experiences breakthrough heartburn 2-3 times weekly, especially after large meals and when lying down at night. Notes worse symptoms with spicy foods and coffee. Denies dysphagia, odynophagia, or weight loss. Has been sleeping with head elevated and avoiding late evening meals. No alcohol use. Quit smoking 5 years ago. Reports increased work stress affecting eating schedule.

Objective

  • Vital Signs:
    • BP: 132/78 mmHg
    • HR: 74 bpm
    • RR: 16/min
    • Temp: 98.6°F
    • BMI: 29.8 kg/m²
  • Physical Examination:
    • General: Well-appearing male in no acute distress
    • HEENT: Oropharynx clear, no dental erosions
    • Neck: No lymphadenopathy
    • Chest: Clear to auscultation
    • Abdomen:
      • Soft, non-tender
      • No epigastric tenderness
      • Normal bowel sounds

Assessment

  1. Gastroesophageal Reflux Disease (ICD-10: K21.9)
    • Partially controlled on current therapy
    • Lifestyle factors contributing
    • No alarm symptoms
  2. Overweight (ICD-10: E66.3)
    • Contributing to GERD symptoms

Plan

  1. Medications:

    • Increase omeprazole to 40mg daily
    • Add ranitidine 150mg as needed for breakthrough symptoms

  2. Lifestyle Modifications:

    • Continue elevation of head while sleeping
    • Avoid meals within 3 hours of bedtime
    • Weight loss goal of 10-15 pounds
    • Identify and avoid dietary triggers

  3. Patient Education:

    • Review GERD dietary guidelines
    • Stress management techniques
    • Importance of regular meal timing

  4. Monitoring:

    • Keep symptom diary
    • Track dietary triggers
    • Record frequency of breakthrough symptoms

  5. Follow-up:

    • Return in 6 weeks to assess response
    • Earlier if symptoms worsen
    • Consider endoscopy if symptoms persist

CPT Code: 99213 (Level 3 Established Patient Visit)

8. Osteoarthritis Management

Description

The patient presents for follow-up of knee osteoarthritis with increasing pain and mobility concerns.

SOAP Note

Patient Name: Barbara Wilson

Date of Visit: 09/08/2024

Subjective

Barbara Wilson, a 68-year-old female, presents for follow-up of bilateral knee osteoarthritis. Reports increased pain in right knee over past month, rating pain as 6/10 at rest and 8/10 with activity. Morning stiffness lasts 30 minutes. Notes difficulty with stairs and getting up from seated position. Currently using acetaminophen 650mg three times daily and topical diclofenac with moderate relief. Completed physical therapy 3 months ago but reports decreased compliance with home exercise program. Uses cane for longer distances.

Objective

  • Vital Signs:
    • BP: 138/82 mmHg
    • HR: 72 bpm
    • RR: 16/min
    • Temp: 98.4°F
    • BMI: 32.4 kg/m²
  • Physical Examination:
    • Musculoskeletal:
      • Right knee: Moderate effusion, crepitus with ROM
      • Left knee: Mild crepitus, no effusion
      • Bilateral knees: No erythema or warmth
    • Range of Motion:
      • Right knee: 10-95 degrees with pain
      • Left knee: 0-110 degrees with minimal pain
    • Strength: 4/5 bilateral lower extremities
    • Gait: Antalgic, favoring right leg

Assessment

  1. Bilateral Knee Osteoarthritis (ICD-10: M17.0)
    • Right worse than left
    • Moderate to severe symptoms
    • Affecting mobility and ADLs
  2. Obesity (ICD-10: E66.01)
    • Contributing to joint stress
  3. Deconditioning
    • Due to decreased activity level

Plan

  1. Medications:

    • Continue acetaminophen and topical diclofenac
    • Add meloxicam 7.5mg daily with meals
    • Consider right knee corticosteroid injection

  2. Physical Therapy:

    • Referral for new course of PT
    • Focus on strengthening and ROM
    • Gait training with assistive device

  3. Lifestyle Modifications:

    • Weight management counseling
    • Low-impact exercise program
    • Activity modification strategies

  4. Assistive Devices:

    • Proper cane height adjustment
    • Consider bilateral walking poles
    • Bathroom safety evaluation

  5. Follow-up:

    • Return in 4 weeks
    • Consider orthopedic referral if no improvement
    • Monitor response to new medication

CPT Code: 99214 (Level 4 Established Patient Visit)

9. Depression with Anxiety

Description

The patient presents for follow-up of depression and anxiety with concerns about medication side effects and stress management.

SOAP Note

Patient Name: Jennifer Martinez

Date of Visit: 09/09/2024

Subjective

Jennifer Martinez, a 35-year-old female, presents for follow-up of depression and anxiety. Has been taking sertraline 50mg daily for 6 weeks with partial improvement in mood but reports continued anxiety, especially in social situations. Sleep has improved but still has difficulty falling asleep. Appetite normal. Reports mild nausea with medication. PHQ-9 score decreased from 18 to 12. GAD-7 score is 14. Attending weekly counseling. Denies suicidal ideation or self-harm thoughts. Works as teacher, notes increased stress with new school year.

Objective

  • Vital Signs:
    • BP: 118/72 mmHg
    • HR: 78 bpm
    • RR: 16/min
    • Temp: 98.6°F
  • Physical Examination:
    • General: Well-groomed, mildly anxious
    • Psychiatric:
      • Alert and oriented x3
      • Affect mildly restricted
      • Speech normal rate and rhythm
      • Thought process logical
      • No psychotic symptoms
  • Screening Tools:
    • PHQ-9: 12 (moderate depression)
    • GAD-7: 14 (moderate anxiety)

Assessment

  1. Major Depressive Disorder (ICD-10: F32.1)
    • Moderate improvement on sertraline
    • Residual symptoms present
  2. Generalized Anxiety Disorder (ICD-10: F41.1)
    • Minimal improvement
    • Social anxiety features
  3. Adjustment Disorder (ICD-10: F43.23)
    • Work-related stressors

Plan

  1. Medications:

    • Increase sertraline to 75mg daily
    • Take with food to minimize GI side effects
    • Consider adding as-needed anxiolytic

  2. Counseling:

    • Continue weekly therapy
    • Focus on stress management
    • Develop coping strategies

  3. Lifestyle Modifications:

    • Sleep hygiene review
    • Regular exercise program
    • Mindfulness techniques

  4. Work Accommodations:

    • Discuss potential workplace adjustments
    • Time management strategies
    • Setting boundaries

  5. Follow-up:

    • Return in 3 weeks
    • Continue PHQ-9 and GAD-7 monitoring
    • Emergency contact information provided

CPT Code: 99214 (Level 4 Established Patient Visit)

10. Annual Wellness Visit

Description

The patient presents for annual wellness visit with focus on preventive care and health maintenance.

SOAP Note

Patient Name: Richard Clark

Date of Visit: 09/10/2024

Subjective

Richard Clark, a 55-year-old male, presents for annual wellness visit. Reports generally good health with no acute concerns. Exercises 3 times weekly with walking and light weights. Following healthy diet with occasional indulgences. No tobacco use, occasional alcohol (2-3 drinks/week). Family history significant for father with MI at age 60 and mother with breast cancer at age 65. Up to date on flu vaccine but due for other immunizations. Last colonoscopy at age 50 was normal.

Objective

  • Vital Signs:
    • BP: 126/78 mmHg
    • HR: 68 bpm
    • RR: 16/min
    • Temp: 98.6°F
    • BMI: 24.8 kg/m²
  • Physical Examination:
    • General: Well-appearing male
    • HEENT: PERRLA, TMs clear, oropharynx normal
    • Neck: No lymphadenopathy, thyroid normal
    • Lungs: Clear to auscultation
    • Heart: Regular rate and rhythm, no murmurs
    • Abdomen: Soft, non-tender, no masses
    • Skin: No concerning lesions
    • Neurological: Grossly intact
  • Recent Labs:
    • Lipid Panel: Total Cholesterol 190, LDL 110, HDL 45
    • Fasting Glucose: 92
    • PSA: 1.2

Assessment

  1. Routine Health Maintenance (ICD-10: Z00.00)
    • Generally healthy
    • Due for preventive services
  2. Family History
    • Cardiovascular disease
    • Breast cancer
  3. Cardiovascular Risk Assessment
    • Multiple risk factors present

Plan

  1. Preventive Services:

    • Schedule colonoscopy (due at 55)
    • Update Tdap vaccination
    • Recommend Shingrix vaccine
    • Schedule cardiac stress test

  2. Screening:

    • Annual PSA monitoring
    • Skin cancer screening
    • Depression screening
    • Continue annual lipid panel

  3. Lifestyle Counseling:

    • Continue current exercise routine
    • Maintain healthy diet
    • Stress management
    • Sleep hygiene

  4. Risk Reduction:

    • Review cardiovascular risk factors
    • Discuss aspirin prophylaxis
    • Sun protection education

  5. Follow-up:

    • Schedule follow-up in 1 year
    • Earlier for any concerns
    • Complete recommended screenings

CPT Code: 99395 (Established Patient Annual Wellness Visit, age 40-64)

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