Episodic / Focused SOAP Note Template

Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
* C, 32, Female, White
S.
CC – Patient went to the clinic as she was “feeling tired” and because her “hair [is] falling out”. She experienced weight gain despite her decrease in appetite. Patient admits not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.
HPI: 32-year-old WW complaining of chronic fatigue for 1 month. She feels tired most of the day, but is still able to complete her regular household task. She is also able to enjoy her hobbies, but with greater difficulty than usual. Patient also sleeps for around 8 hours, but she feels that “she is not sleeping well” or that she feels well-rested. Colleagues at school, sometimes ask her if she has any problems, especially when patient’s performance is adversely affected. Patient admits that ‘something’ is wrong, but she ‘did not think’ it was serious, which is the reason why she consulted a month after the onset of the symptoms.
Current Medications: Patient is taking multivitamins once a day for the last 2 months. She regularly uses wild rosemary (Ledum palustre) as homeopathic treatment for toothache. Denies use of any other medications other than stated.
Allergies: Patient denies any known causes of allergy.
PMHx: Patient not personally aware of immunization status. No recent tetanus immunization. Vaccinated for MMR, HPV, and DTaP about 4 years ago.
Soc Hx: Patient likes going for a walk, reading and playing tennis. She regularly drinks beer twice a week in moderated quantities. Patient stopped smoking tobacco 3 years ago. Denies any substance abuse. Goes out with friends once every two weeks.
Fam Hx: Parents have a history of diabetes Type II. Patient not aware of any other possible genetic diseases.
ROS:
* GENERAL:  Gained 30 pounds since last year; experiences chills, weakness, and fatigue.
* H...