⚠️ Disclaimer: This note/template is for documentation support and educational purposes only. The note was created with ChatGPT AI technology. It is not medical advice or a substitute for clinical judgment. Always verify details, tailor documentation to the specific patient, and follow applicable guidelines and policies.
ChatGPT Prompt Used: Create an urgent care SOAP note for a patient with abdominal pain caused by constipation. It should include a complete ROS with at least 10 systems, a focused physical exam that includes an assessment/plan with patient education including emergency return precautions. Make it concise, easy to fill in, and clinically appropriate for urgent care setting.
S: Subjective
- CC: Abdominal pain x ___ days.
- HPI: Patient reports abdominal pain localized to ___ [quadrant/diffuse]. Pain is ___ [dull/crampy/aching], severity ___/10. Last BM ___ days ago. Pain worsens with eating, improves somewhat with passing gas. Associated sx: ___ [bloating, nausea, decreased appetite]. Denies vomiting, hematemesis, melena, hematochezia, urinary sx, or fever.
- PMH/PSH: ___
- Meds/Allergies: ___
- Social Hx: ___ [diet, hydration, activity, tobacco/ETOH]
- Family Hx: ___ [colon cancer, GI disorders]
ROS (10+ systems)
- Constitutional: No fever, chills, or weight loss.
- Eyes: No visual changes, redness, or discharge.
- ENT: No sore throat, congestion, rhinorrhea, or ear pain.
- CV: No chest pain, palpitations, syncope.
- Resp: No SOB, cough, wheezing.
- GI: +Constipation, +abdominal pain, +bloating. No diarrhea, vomiting, hematemesis, melena, hematochezia.
- GU: No dysuria, frequency, hematuria, flank pain.
- MSK: No joint pain, back pain, myalgias.
- Skin: No rash, lesions, jaundice.
- Neuro: No headache, dizziness, weakness, numbness.
- Psych: No anxiety, depression, confusion.
O: Objective
- VS: T ___ °F HR ___ BP ___ RR ___ SpO₂ ___%
- General: Alert, NAD.
- HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Oropharynx clear, moist mucous membranes. TMs intact, no erythema.
- Neck: Supple, no lymphadenopathy.
- CV: RRR, no murmurs.
- Resp: CTAB, no distress.
- Abdomen: Soft, mildly distended. Hypoactive BS. Mild diffuse tenderness ___ [location]. No rebound, guarding, or masses. No hepatosplenomegaly.
- Back: No CVA tenderness.
- Skin: Warm, dry, intact. No jaundice.
- Extremities: No edema, cyanosis, or clubbing.
- Neuro: A&Ox3, CN II–XII grossly intact, no focal deficits.
A: Assessment
- Abdominal pain, most consistent with constipation.
- Differential: constipation, gastroenteritis, IBS, bowel obstruction, diverticulitis.
P: Plan
- Diagnostics: Consider plain abdominal X-ray if obstruction suspected; otherwise not indicated.
- Treatment: Increase hydration, fiber, physical activity. OTC stool softener or osmotic laxative (polyethylene glycol) as directed.
- Education:
- Encourage hydration and fiber. Avoid prolonged straining.
- Use OTC laxatives as needed but seek care if ineffective.
- Emergency precautions: Return to ED/UC immediately for worsening or severe abdominal pain, persistent vomiting, inability to tolerate PO, fever/chills, blood in stool or vomit, inability to pass stool or gas, or new concerning symptoms.
- Follow-up: PCP in ___ days if no improvement. GI referral if recurrent/chronic.
- Disposition: Discharged home in stable condition