SOAP note example for Occupational Therapist

Subjective

Ruby stated that she feels 'energized' and 'happy.' She states that getting out of bed in the morning is markedly easier and she feels 'motivated to find work.' She has also stated that her 'eating and sleeping has improved,' but that she is concerned, she is 'overeating.'

Objective

Ruby attended her session and was dressed in a matching pink tracksuit. Her personal hygiene was good, and she had taken great care to apply her makeup and paint her nails. Ruby appeared fresh and lively. Her compliance with her medication is good, and she has been able to complete her jobseekers form.

Assessment

Ruby presented this morning with markedly improved affect and mood. Her speech was normal in rate and pitch and appeared to flow easily. Her thoughts were coherent, and her conversation was appropriate. Ruby's appearance and posture were different from what they were in our last session. Ruby's medication appears to be assisting her mental health significantly.

Plan

Ruby to see me again in one week Ruby to contact me if she requires any assistance in her job seeker process Ruby to continue on her medication Dr. Smith and I to review this new pertinent information in MDT and discuss possible diagnoses we had considered

SOAP note example for Dentistry

Subjective

Chief complaint: 56-year-old female presents with a "painful upper right back jaw for the past week or so" History of Present Illness: historically asymptomatic Medical History: Medical conditions: Nil. Medications: Nil. Allergies: Paracetamol Social History: Tobacco, ETOH

Objective

Vitals: BP 133/91 HR: 87 Temp: 98.7 Clinical Exam Extraoral (Swelling, Asymmetry, Pain, Erythema, Paraesthesia, TMI): Nil. Intraoral (Exudate, Erythema, Hemorrhage, Occlusion, Pain, Biotype, Hard Tissue, Swelling, Mobility): #17 (FDI #27) Supra erupted and occuding on pericoronal tissues of #16 #16 Partially erupted, erythematous gingival tissue, exudate, pain to palpate Radiology (PA Pano, CT):

Assessment

1. Smoker (1 pack per week) 2. #17 supraerupted and occluding on opposing gingiva 3. #16 Pericoronitis

Plan

1. Extraction #17 today 2. Antibiotics (10-day course of penicillin) 3. Follow up (pm)

SOAP note example for Spe

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