SOAP Note: CC: Patient presents for a follow-up of chronic h…

SOAP Note: CC: Patient presents for a follow-up of chronic heartburn and acid reflux (GERD). Reports nighttime discomfort. (Add more detail).  VS: VS WNL Assessment: GERD, uncomplicated Plan: Continue Omeprazole 20mg daily Advise avoiding trigger food (spicy, fatty, caffeine) Elevate head of bed at night Encourage weight management if applicable  Follow up in 3-6 months or sooner if symptoms worsen