Disclaimer:
This document is for educational and workflow support only and is not medical advice. It was generated with the assistance of AI. Errors may occur; all content must be carefully reviewed, edited, and verified by a licensed provider. Liability rests with the clinician who adopts and signs the documentation.
ChatGPT Prompt: Act as a nurse practitioner and write a detailed SOAP note for a healthy patient with an acute viral upper respiratory infection. The exam should show no abnormal findings beyond mild URI symptoms, no evidence of secondary bacterial infection, and no antibiotics prescribed. In the Plan, include supportive care recommendations such as fluids, rest, humidifier, warm tea with honey, and OTC therapies. Add return precautions with emphasis on seeking care sooner if red flag symptoms develop.
SOAP Note – Acute Viral Upper Respiratory Infection
S: Subjective
- Patient presents with nasal congestion, rhinorrhea, sore throat, and mild nonproductive cough for the past 3–4 days.
- Reports low-grade subjective fever at onset but afebrile currently.
- Denies chest pain, shortness of breath, wheezing, productive cough, ear pain, rash, or GI symptoms.
- Denies recent sick contacts beyond common community exposures.
- No significant past medical history. No daily medications. No known drug allergies.
- Immunizations up to date.
O: Objective
- General: Alert, nontoxic, no acute distress.
- Vital Signs: Stable; afebrile.
- HEENT: Mild nasal congestion, clear rhinorrhea. Oropharynx moist, mild posterior pharyngeal erythema, no exudate or tonsillar enlargement. TMs clear bilaterally. No cervical lymphadenopathy.
- Cardiovascular: Regular rate and rhythm, no murmurs.
- Respiratory: Clear breath sounds bilaterally, no wheezes, rales, or rhonchi. Normal respiratory effort.
- Abdomen: Soft, nondistended, nontender.
- Skin: Warm, dry, no rash.
A: Assessment
- J06.9 – Acute upper respiratory infection, unspecified
- Otherwise healthy patient. No evidence of secondary bacterial infection.
P: Plan
- Supportive care: increase fluids, rest, use of humidifier, warm tea with honey for throat comfort, and saline spray for congestion.
- OTC therapies discussed: acetaminophen/ibuprofen as needed for fever or discomfort; decongestants, saline rinses, throat lozenges, or honey for cough relief (as age-appropriate).
- Avoid unnecessary antibiotics; discussed viral etiology.
- Return precautions reviewed: seek care sooner if red flag symptoms develop (fever >101.5°F, shortness of breath, chest pain, purulent sputum, ear pain, dehydration, or rapidly worsening symptoms).
- Follow up with PCP if no improvement in 7–10 days or sooner if concerns.
- Patient/guardian verbalized understanding and agreement with plan.