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Posted: February 15th, 2023
Sample SOAP note for a patient diagnosed with COVID-19:
S: CC: “I’ve had a cough, fever, and body aches for the past 3 days.”
HPI: 48-year-old male presents with 3 days of cough, fever up to 101F, and body aches. Reports fatigue and headache. Received positive COVID-19 rapid antigen test at home yesterday. Up to date on COVID-19 vaccines with two mRNA doses and one booster. Works as a teacher and reports potential exposure from an ill student last week.
O: Vitals: T 100.4F, HR 100, RR 20, BP 130/80. General appearance is fatigued. Lungs have scattered wheezes bilaterally. O2 sat 94% on room air. Throat mildly erythematous without exudates. Heart and lung exam otherwise normal.
A: COVID-19.
P: Reassurance and education on COVID-19 management at home. Recommend rest, hydration, use of acetaminophen or ibuprofen for fever and body aches. Advise isolation for 5 days and to wear a well-fitting mask for an additional 5 days if around others. Follow up if symptoms worsen or do not improve after 5 days.
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