Family Medicine SOAP Note Example: Acute Bronchitis plus Preventive Care
A primary care note that handles today's concern, a chronic condition and the preventive care that's due, all in one visit.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient family medicine visitPatient: Fictional patient: 46-year-old woman with hypertension
SSubjective
Reason for visit
"This cough won't go away." Also due for a blood pressure check.
HPI
12 days of cough that began with a cold (runny nose and sore throat, now resolved). Cough was dry and is now productive of clear-to-yellow sputum. Fever only on day 2. No shortness of breath, wheezing, chest pain, hemoptysis, night sweats or weight loss. No coughing fits or post-cough vomiting. Children at home have had colds. Honey and dextromethorphan help partially.
Chronic conditions
Hypertension: home readings 120s-130s/80s, taking amlodipine every day, no ankle swelling or other side effects.
Medications / allergies
Amlodipine 5 mg daily. Allergy: sulfa (hives).
Social / psychosocial
Teacher; lives with husband and two children (8 and 11). Never smoker. Alcohol: 1-2 drinks a month. Walks 3 days a week.
Preventive history
Mammogram 3 years ago. Never had colorectal cancer screening. Pap/HPV co-test 2 years ago, normal. Tdap 2017. No flu vaccine yet this season.
OObjective
Vital signs
BP 128/78, HR 78, RR 16, T 98.4 °F, SpO2 98% on room air. Weight 156 lb, BMI 26.1.
Exam
General: well appearing, occasional cough, speaking in full sentences. HEENT: tympanic membranes normal; oropharynx without exudate; no sinus tenderness. Neck: no lymphadenopathy. Lungs: clear bilaterally; no wheezes, crackles or egophony; normal work of breathing. Heart: regular rate and rhythm, no murmur.
Data
No testing needed today.
AAssessment
Today's concern
Acute bronchitis, most likely viral: cough under 3 weeks following a cold, with normal vital signs and a normal lung exam. Pneumonia is unlikely (no fever, tachycardia, tachypnea or focal findings), so no chest X-ray or antibiotics. Pertussis considered and unlikely (no paroxysms, whoop or post-tussive vomiting). Asthma and reflux less likely.
Chronic conditions
Hypertension — at goal (under 130/80) on amlodipine; home readings agree.
Health maintenance
Due: colorectal cancer screening, screening mammogram, influenza vaccine. Up to date: Tdap, cervical cancer screening.
PPlan
By problem
1. Acute bronchitis: supportive care (honey, fluids, dextromethorphan as needed). Explained that the cough can last up to 3 weeks and antibiotics would not shorten it. 2. Hypertension: continue amlodipine 5 mg daily and home monitoring.
Preventive
Influenza vaccine given today. Screening mammogram ordered. Colorectal screening: discussed colonoscopy versus stool-based testing; patient chose FIT, kit given.
Counseling
Shared decision on colorectal screening as above. Encouraged continuing regular walking.
Follow-up
Return in 6 months for blood pressure, sooner if needed. Will call with FIT and mammogram results. Return precautions: fever, shortness of breath, chest pain, blood in sputum, or cough lasting beyond 3 weeks.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
It lists every concern the patient brought, then addresses each one.
The chronic condition gets an explicit control status (at goal) backed by numbers.
Preventive care is checked against what's due, and the screening choice is a shared decision.
The Assessment explains why no X-ray or antibiotics were given, which is what stewardship looks like in a note.
What students often miss
Screenings and vaccines that are due
Patient goals and barriers
Specific follow-up interval
Family Medicine SOAP note template
Continuity care: today's concern plus chronic disease and prevention, in the context of the whole person.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.