Tina SOAP Note Sample Tina SOAP Note Tina is a 27-year-old female who presents to the clinic complaining of a painful burning sensation in her left labial area for 3 days. She reports recently having unprotected vaginal intercourse with a new male partner. Upon examination, you note fluid-filled vesicles on the left labia minora that are painful to touch.

Tina SOAP Note Sample
Tina SOAP Note Tina is a 27-year-old female who presents to the clinic complaining of a painful burning sensation in her left labial area for 3 days. She reports recently having unprotected vaginal intercourse with a new male partner. Upon examination, you note fluid-filled vesicles on the left labia minora that are painful to touch.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

1. Subiective:

a. What other relevant questions should you ask regarding the HPI?

b. What other medical history questions should you ask?

c. What other social history questions should you ask?

2. Obiective:

a. Explain what POCT you will you order and perform, and discuss your rationale for ordering and performing each test.

3. Assessment/ Diagnosis:

a. What are your presumptive and differential diagnoses, and why?

b. Any other diagnosis or differential diagnosis you would like to add?

4. Plan:

a. What will you prescribe for this patient? Why? (assume one of your lab test results is positive), Explain what medications and treatments you would recommend

b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatments), partner notification, and follow-up plan of care.

c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)

d. Explain complications that can occur if patient does not comply with treatment regimen. Please refer to evidence-based guidelines to support your decision-making.

SOAP Note Sample 1
Subjective:
Chief Complaint (CC): Patient is a 27-year-old female complaining of a painful burning sensation in her left labial area for the past 3 days.
History of Present Illness (HPI): The patient reports recent unprotected vaginal intercourse with a new male partner.
Objective:
Physical Exam Findings: Upon examination, fluid-filled vesicles are noted on the left labia minora that are painful to touch.
Assessment:
Medical Decision Making (MDM): The patient’s symptoms and physical exam findings are suggestive of a sexually transmitted infection, possibly Herpes Simplex Virus (HSV).
Plan:
Treatment Plan: The patient should be tested for HSV and other sexually transmitted infections. If the test results confirm HSV, antiviral medication will be prescribed. The patient should also be educated about safe sex practices to prevent future infections.
Here’s how you can structure this information in a table:

Subjective Objective Assessment Plan
27-year-old female complaining of a painful burning sensation in her left labial area for the past 3 days. Reports recent unprotected vaginal intercourse with a new male partner. Fluid-filled vesicles noted on the left labia minora that are painful to touch. Symptoms and physical exam findings suggest a sexually transmitted infection, possibly Herpes Simplex Virus (HSV). Test for HSV and other sexually transmitted infections. If confirmed, prescribe antiviral medication. Educate patient about safe sex practices.
ADDITIONAL INSTRUCTIONS FOR THE CLASS – Tina SOAP Note Sample