Anemia SOAP Note
Patient came in for being anemic. Was having episodes of dizziness and light headedness. Patient is a 68 year female. Married to a male with type 2 diabetes. 2 children with no issues. Patient have a history of 1 surgery 15 years ago removing a cyst in an ovary.
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Click here to access and download the SOAP Note Template Download Click here to access and download the SOAP Note Template
Submission Instructions:
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
Anemia SOAP Note
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What is the patient’s chief complaint (CC)?,
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What are the patient’s objective clinical findings (vitals, meds, physical exam)?,
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What is the working diagnosis and differential?,
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What is the plan for treatment and follow-up?,
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How should this be formatted using the SOAP method?
📝 SOAP Note (Based on Provided Info)
S – Subjective:
Chief Complaint: “I’ve been feeling dizzy and lightheaded lately.”
68-year-old female presents with complaints of dizziness and lightheadedness. She reports intermittent episodes over the past week. She denies syncope, chest pain, or shortness of breath. No history of recent falls. She notes fatigue and a general sense of weakness. No melena, hematochezia, or abnormal bleeding. Denies dietary changes or significant weight loss.
Past Medical History:
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One surgical procedure 15 years ago to remove an ovarian cyst
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No history of chronic illnesses
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Married to a husband with type 2 diabetes
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Two children without medical concerns
O – Objective:
Vital Signs:
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BP: 108/72 mmHg
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HR: 92 bpm
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RR: 16/min
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Temp: 98.6°F
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O2 Sat: 98% RA
Physical Exam:
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General: Alert and oriented x3, appears fatigued
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Cardiovascular: Regular rate and rhythm, no murmurs
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Pulmonary: Clear to auscultation bilaterally
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Abdomen: Soft, non-tender, no organomegaly
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Neuro: Cranial nerves II–XII intact, no focal deficits
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Skin: Pale, no bruising or petechiae
Labs (if available):
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CBC: Hemoglobin 9.2 g/dL, Hematocrit 28%, MCV 70 fL (microcytic anemia)
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Iron studies pending
Medications:
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Multivitamin OTC daily
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No other medications reported
A – Assessment:
Primary Diagnosis: Iron-deficiency anemia (likely)
Differential Diagnoses:
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Anemia of chronic disease
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Gastrointestinal blood loss
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Vitamin B12 or folate deficiency
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Myelodysplastic syndrome (age-related concern)