Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Encounter:
Subjective (S):
Document the patient’s perspective on their health concerns in their own words whenever possible.
Use quotations to capture key details. This section may include:
Chief Complaint (CC): The main reason for seeking medical attention.
History of Present Illness (HPI): A detailed exploration of the CC using elements like location, onset, duration, severity, etc. (see previous template for HPI)
Past Medical History (PMHx): A summary of significant past medical conditions, surgeries, allergies, and medications.
Social History (SH): Brief information about social determinants of health such as living situation, occupation, tobacco use, alcohol use, and social activities.
Family History (FHx): A summary of relevant medical conditions in the patient’s family.
Review of Systems (ROS): A systematic inquiry into various body systems to identify any other symptoms that may not have been volunteered by the patient.
Objective (O):
Document your findings from the physical examination. Organize them systematically by body system or using a head-to-toe approach.
Include vital signs (blood pressure, heart rate, temperature, respiratory rate, oxygen saturation).
Note any abnormal findings using relevant medical terminology.
Document laboratory test results, imaging studies, or other diagnostic procedures performed.
Assessment (A):
Integrate the information gathered in the Subjective and Objective sections.
Formulate a differential diagnosis, listing the most likely causes of the patient’s condition(s) based on the available information.
Narrow down the possibilities considering test results and clinical reasoning.
State your final diagnosis if possible.
Plan (P):
Outline the treatment plan for the patient. This may include:
Diagnostic tests needed to confirm or rule out a diagnosis.
Medications prescribed, including dosage, route, and frequency.
Non-pharmacological interventions (e.g., dietary modifications, physical therapy).
Referral to specialists if needed.
Patient education regarding their condition, medications, or self-care strategies.
Follow-up plan, including the date and time of the next appointment or instructions for contacting the healthcare provider if necessary.
Additional Considerations:
This is a general template, and you may need to adjust it depending on the specific encounter and your specialty.
Documenting clearly, concisely, and using proper medical terminology is essential.
Ensure the SOAP note adheres to your facility’s documentation standards and HIPAA regulations regarding patient privacy.
By following this SOAP Note Template, you can create a well-structured and informative patient note that effectively communicates the patient’s condition, assessment, and plan for further care.