SOAP Note Example
Urgent Care SOAP Note Example
Below is a complete SOAP note example for an urgent care visit evaluating an adult patient presenting with acute pharyngitis. This example demonstrates efficient documentation appropriate for a high-volume clinical setting while maintaining thorough medical decision-making, Centor criteria scoring, rapid diagnostic testing, and clear discharge instructions with return precautions.
Complete Urgent Care Note
SUBJECTIVE:
Patient is a 29-year-old female presenting with sore throat for 3 days with progressive worsening. Describes the pain as constant, rated 7/10, worse with swallowing — has difficulty swallowing solid foods and has been limiting intake to liquids and soft foods for the past 24 hours. Reports subjective fever at home with measured temperature of 101.3°F last night. Associated symptoms: bilateral anterior neck swelling and tenderness, mild headache, fatigue, and body aches. Denies cough, nasal congestion, rhinorrhea, hoarseness, ear pain, shortness of breath, drooling, or difficulty opening mouth. Denies rash, joint pain, nausea, vomiting, or diarrhea. No known sick contacts at home but works as a schoolteacher and reports several students have been absent with strep throat in the past two weeks. No recent travel. No history of recurrent pharyngitis or prior peritonsillar abscess. No history of rheumatic fever. Last episode of strep throat was approximately 4 years ago, treated with amoxicillin with resolution. Past medical history: seasonal allergies, mild intermittent asthma (uses albuterol inhaler PRN, not needed in over 6 months). Surgical history: none. Medications: cetirizine 10 mg daily, albuterol inhaler PRN. Allergies: penicillin — developed a generalized maculopapular rash at age 12 (not anaphylaxis, not hives). Immunizations: up to date including COVID-19. Social history: non-smoker, occasional alcohol, no illicit drug use.
OBJECTIVE:
Vital signs: temperature 101.6°F (38.7°C) oral, blood pressure 118/72 mmHg, heart rate 92 bpm, respiratory rate 16, SpO2 99% on room air. General: alert, oriented, mildly ill-appearing, speaking in a normal voice without stridor or muffling. HEENT: oropharynx — bilateral tonsillar erythema and edema (3+ tonsils), white-yellow tonsillar exudates present bilaterally, palate without petechiae or bulging, uvula midline and non-deviated, no peritonsillar fullness or asymmetry, no trismus (mouth opens fully without limitation). No oral ulcers or vesicles. Bilateral anterior cervical lymphadenopathy — tender, mobile, approximately 1.5 cm largest node on the left — no posterior cervical lymphadenopathy. Ears: tympanic membranes clear bilaterally with normal light reflex, no erythema or effusion. Nose: no rhinorrhea, turbinates mildly boggy bilaterally (consistent with allergy history), no purulent discharge. Neck: supple, no meningismus. Cardiovascular: regular rate and rhythm, no murmurs. Lungs: clear to auscultation bilaterally, no wheezes, no stridor. Skin: no rash, no scarlatiniform eruption. Centor criteria: fever >100.4°F (1 point), tonsillar exudates (1 point), tender anterior cervical lymphadenopathy (1 point), absence of cough (1 point) — total Centor score: 4/4. Modified Centor (McIsaac): age 15-44 (0 points) — total McIsaac score: 4/5. Rapid antigen detection test (RADT) for Group A Streptococcus: positive. Throat culture: not sent (RADT positive in a high-pretest-probability patient; backup culture not indicated per current guidelines).
ASSESSMENT:
Acute Group A Streptococcal pharyngitis, confirmed by positive rapid antigen detection test in the context of a Centor score of 4/4 and high-pretest-probability clinical presentation (tonsillar exudates, fever, anterior lymphadenopathy, absence of cough). Peritonsillar abscess is excluded based on midline uvula, absence of peritonsillar bulging or asymmetry, absence of trismus, absence of drooling, and normal voice quality. Infectious mononucleosis is considered unlikely given the acute onset over 3 days without posterior cervical lymphadenopathy, hepatosplenomegaly, or prolonged fatigue, though cannot be fully excluded clinically — will not pursue Monospot testing at this time given the confirmed strep result and plan for non-amoxicillin antibiotic. Patient has a documented penicillin allergy (maculopapular rash, non-anaphylactic) — per guidelines, first-generation cephalosporins may be used with caution in patients with non-severe penicillin allergy (cross-reactivity rate approximately 1-2%), but given patient preference and history, will prescribe cephalexin as first-line alternative.
PLAN:
Cephalexin 500 mg PO twice daily for 10 days — dispensed #20, no refills. Discussed with patient that her penicillin allergy (maculopapular rash without anaphylaxis or urticaria) is classified as a non-severe allergy, and first-generation cephalosporins are considered safe with a very low cross-reactivity risk; patient verbalized understanding and consented to the cephalexin prescription. Instructed patient to discontinue cephalexin and seek immediate medical attention if she develops hives, facial or throat swelling, difficulty breathing, or any new rash. Symptomatic management: ibuprofen 400 mg PO every 6 hours as needed for pain and fever (take with food), may alternate with acetaminophen 1000 mg PO every 6 hours if additional pain relief is needed. Encourage warm salt water gargles (half teaspoon salt in 8 ounces warm water) several times daily for sore throat relief. Maintain adequate oral hydration — soft foods and warm or cool liquids as tolerated. Rest for the next 24-48 hours. Patient may return to work 24 hours after starting antibiotic therapy and once fever has resolved without antipyretics. Patient is considered non-contagious after 12-24 hours of antibiotic therapy. Discharge instructions and return precautions: return to urgent care or emergency department if — difficulty breathing or swallowing, inability to tolerate oral fluids, drooling or inability to manage secretions, worsening or new rash, voice change or muffled voice ("hot potato" voice), symptoms worsen or fail to improve after 48-72 hours of antibiotic therapy, or fever persists beyond 48 hours of antibiotic use. Complete the full 10-day antibiotic course even if symptoms improve to prevent rheumatic fever and treatment failure. Follow up with PCP within 2-4 weeks if interested in formal penicillin allergy evaluation and possible delabeling, which could broaden future antibiotic options.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Urgent care documentation must be efficient yet thorough. For pharyngitis, capture the Centor criteria components within the history: presence or absence of fever (with measured temperature if available), cough status (its absence is a criterion), and perceived neck swelling. Document pertinent negatives that help exclude dangerous diagnoses — no drooling, trismus, or voice changes rules out peritonsillar abscess; no rash addresses scarlet fever. The allergy history is critical because penicillin allergy directly changes the antibiotic selection and must include the specific reaction type (rash vs. anaphylaxis) to guide safe prescribing. Known sick contacts and exposure history strengthen the pretest probability for strep.
Objective
The urgent care objective section prioritizes a focused, efficient examination targeting the chief complaint and dangerous mimics. Document the oropharyngeal exam in enough detail to characterize the tonsillar findings (size, erythema, exudates) and explicitly exclude peritonsillar abscess (midline uvula, no asymmetry, no trismus). Record lymphadenopathy distribution — anterior cervical supports strep, posterior cervical raises concern for mononucleosis. Calculate and document the Centor score with each criterion listed to justify the testing decision. Report the rapid strep test result and whether a backup culture was sent, with brief rationale if it was not. This structured approach demonstrates that the clinical decision-making followed evidence-based guidelines.
Assessment
In the urgent care setting, the assessment must efficiently confirm the diagnosis, exclude emergent differential diagnoses, and document the medical reasoning behind the treatment selection — particularly when the treatment pathway deviates from the standard first-line agent. For pharyngitis, explicitly state how peritonsillar abscess was excluded based on physical findings. Address the penicillin allergy classification (non-severe vs. severe) and the evidence basis for the chosen alternative antibiotic. This documentation protects the provider medicolegally and demonstrates that the prescribing decision was guideline-concordant and patient-specific rather than reflexive.
Plan
Urgent care plans must include complete prescribing details (medication, dose, route, frequency, duration, quantity), clear symptomatic management instructions patients can follow at home, specific work or school return criteria, and explicit return precautions with the warning signs that should prompt re-evaluation. For antibiotic prescriptions in the setting of a documented allergy, note that the allergy was discussed with the patient, that consent was obtained, and what symptoms should trigger immediate discontinuation. Return precautions should be written in plain language and address the specific complications relevant to the diagnosis — for pharyngitis, these include peritonsillar abscess symptoms, treatment failure indicators, and allergic reaction signs.
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