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Rebecca Krusz Soap Notes
Rebecca Krusz Soap Notes
SUBJECTIVE
Suture removal. Patient returns for removal of stitches place about seven
days ago.
OBJECTIVE
Wound at lateral aspect of the left eye looks well healed. The 5-0 nylon
sutures were removed without difficulty.
ASSESSMENT
Laceration, healed.
PLAN
I advised him to use Vitamin E for scar prophylaxis.
____________________________
Jason Karns, MD
RK
D: 3/16/17
T: 3/16/17
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN (SOAP)
SUBJECTIVE
Patient came in for suture removal from a left knee wound. He is doing well.
OBJECTIVE
Wound appears dry and clean; there are no signs of infection.
ASSESSMENT
Suture removal
PLAN
All 5 sutures were removed. Bandage was applied.
____________________________
Jason Karns, MD
RK
D: 3/16/17
T: 3/16/17
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN (SOAP)
SUBJECTIVE
Michael comes in today for a 15-month examination. Mother has no
complaints. He is feeding himself and putting two words together when
talking. For motor and growth development, he is actually in the 22-month
development. Most recent hemoglobin was 12.3. His is above the 95th
percentile for height; 95th percentile for weight.
OBJECTIVE
Head is normal. Ears are clear. Eyes are clear. Pupils are equal, round, and
reactive to light and accommodation. Throat is clear. Nose is clear. Neck has
good range of motion without nodes. Lungs are clear. Heart has regular rate
and rhythm. Abdomen is soft without masses. Testicles are descended. Back
is straight. He is walking well. He has good muscle tone. See developmental
forms in chart.
ASSESSMENT
Normal well-baby examination.
PLAN
Continue present diet and advance as tolerated. Immunizations were given;
see form. Recheck in 3 months, sooner if needed.
____________________________
Jason Karns, MD
RK
D: 3/16/17
T: 3/16/17