SOAP NOTE
| Patient Initials: | Pt. Encounter Number: | |
| Date: | Age: | Sex: |
| Allergies: Advanced Directives:
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| SUBJECTIVE | ||
| CC:
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| HPI: Describe the course of the patient’s illness:
Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment:
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| Current Medications:
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| PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
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| Family History:
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| Social History:
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| ROS | ||
| General
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Cardiovascular
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| Skin
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Respiratory
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| Eyes
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Gastrointestinal
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| Ears
|
Genitourinary/Gynecological
|
SOAP NOTE
| Nose/Mouth/Throat
|
Musculoskeletal
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| Breast
|
Neurological
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| Heme/Lymph/Endo
|
Psychiatric
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| OBJECTIVE | ||
| Weight BMI | Temp | BP |
| Height | Pulse | Resp |
| PHYSICAL EXAMINATION | ||
| General Appearance
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| Skin
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| HEENT
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| Cardiovascular
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| Respiratory
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| Gastrointestinal
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| Breast
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| Genitourinary
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| Musculoskeletal
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| Neurological
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| Psychiatric
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| Lab Tests |
| Special Tests |
| Diagnosis |
| · Primary Diagnosis-
Evidence for primary diagnosis should be documented in your Subjective and Objective exams.
o Differential Diagnoses–
PLAN including education o Plan: Further testing Medication Education Non-medication treatments · Referrals Follow-up visits
|
| References |
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