Tarrant County College, Northeast

PSYCH 2301

Episodic/Soap Note Format
Episodic SOAP Note Scenario 1
Patient Information
Initials: Mr T., Age: 62 years of age, Sex: Male, Race: AfricanAmerican Referral: None Source: Patient Reliability: Patient seems reliable:
Allergies: Patient denies any known allergies drugs, diets, latex or iodine.
SCC: “Rectal Bleeding for over 1 month”
S (SUBJECTIVE)
HPI: This is a 62-year-old African-American male construction worker present at the outpatient
unit of the clinic complaining of rectal bleeding of over 1 month as the patient noticed a
relatively small amount of blood in every bowel movement. The patient admits having
undergone colonoscopy 2 years ago with normal results, and the patient feels no fever, chills,
dysuria, abnormal urination, or abdominal pain but reports occasional itching and pain of the
rectal region with no noticeable or traceable sores of the rectal region.
MH: Patient is negative for asthma, depression and insomnia. Patient denies any history of
cancer, allergies, diabetes mellitus, stroke, seizures disorders, myocardial infarction (heart
attack), depression, urinary tract infections, clotting or bleeding disorders. Surgical history: Nil
Psychiatric: Patient denies any history/traces o