NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA

(PROGRESS NOTE USING S.O.A.P Note)

# Candidate’s information
1 Surname: ADELAJA Other names: ADENIKE SILIFAT

2 Training institution: ABUTH ZARIA

3 Posting institution (if different from the training institution): Click here to enter text.
4 Supervising consultant for the posting: DR AUDU. I.A..
5
6 Period of posting: From m/d/y: 9 To m/d/y:

7 Posting: GENERAL PSYCHIATRY

8 Type of report: SOAP NOTE

9 Type of encounter ASSESSMENT UNIT CLERKING

10 PROCEDURE (IF APPLICABLE): Click here to enter text stating the procedure e.g ECT, MMPI
ADMINISTRATION, SCORING AND INTERPRETATION.
11 Patient information
12 Initial: M.I Date Date 9
admitted discharged
m/d/y: m/d/y:
SOAP NOTE
Section Entry
13 Subjective (S) Suicidal attempt, persistent sadness, self-neglect
What the client tells you
What pertinent others tell you about
the client
Basically, how the client experiences
the world
14 Objective (O) A young man, poor eyes contact, depressed
Factual
What you as a clinician personally
observe/witness
Written materials received or
available on the patient
Results of Instruments administered
or test done
15 Assessment (A) Depression with suicidal attempt
Summarize the clinician’s clinical
thinking.
A synthesis and analysis of the
subjective and objective portion of
the notes.

16 Plan (P) Tab fluoxetine 20mg daily

Interventions needed or used,
treatment progress, and direction.
Prognosis: the anticipated gains
from the interventions
17 Attestation:
18
Tab VIT BCO II daily
☒I attest that this report is a correct representation of my clinical
encounters with the patient in reference.
☒I attest that my supervising consultant previewed this write-up before
upload.

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 NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA
(PROGRESS NOTE USING S.O.A.P Note)

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