Focused SOAP Note Template Patient Information Paper
Episodic/Focused SOAP Note Template Patient Information: Initials: JM Age: 42 Sex: Male Race: Hispanic S. CC: “I am experiencing pain in my right wrist with tingling and numbness in the thumb and index and middle fingers. I can’t type well at work.” HPI: 42-year-old Hispanic male complaining of pain in his right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. He has been frustrated because the pain causes him to have trouble typing when at work. Location: Wrist Onset: 2 weeks ago Character: Focused SOAP Note Template Patient Information Paper
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pain in his right wrist, with tingling and numbness in the thumb and index and middle fingers Associated signs and symptoms: pain, tingling and numbness © 2021 Walden University, LLC Page 1 of 8 Timing: any time of the day Exacerbating/ relieving factors: activities that involve the right hand/massage Severity: 9/10 pain scale Current Medications: None Allergies: None PMHx: Covid 19 Vaccine, 2020. Denies any other significant past medical and surgical history. Patient denies trauma to his right hand. Soc Hx: JM works and 8 to 5 job as an accountant hence the need to use the computer for a significant part of his normal work day. He does not take alcohol, tobacco or any other illicit drugs. He is married tone wife with 2 children and 1 grandchild. Does not travel often and spends most of his weekends with his grandchild. Focused SOAP Note Template Patient Information Paper