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skills/clinical-reports/assets/soap_note_template.md

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+# SOAP Note Template
+
+## Patient Information
+
+**Patient Name:** [Last, First] or [Patient ID for teaching/research contexts]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Medical Record Number:** [MRN]  
+**Date of Visit:** [MM/DD/YYYY]  
+**Time:** [HH:MM]  
+**Location:** [Clinic, Hospital Floor, ED, etc.]  
+**Provider:** [Your name and credentials]
+
+---
+
+## S - SUBJECTIVE
+
+### Chief Complaint (CC)
+"[Patient's chief complaint in their own words]"
+
+### History of Present Illness (HPI)
+
+[Patient Name] is a [age]-year-old [sex] with a history of [relevant PMHx] who presents with [chief complaint].
+
+**Onset:** [When did symptoms start? Sudden or gradual?]
+
+**Location:** [Where is the symptom? Does it radiate?]
+
+**Duration:** [How long has this been going on?]
+
+**Characterization:** [Describe the quality - sharp, dull, burning, etc.]
+
+**Aggravating factors:** [What makes it worse?]
+
+**Relieving factors:** [What makes it better?]
+
+**Timing:** [Constant or intermittent? Frequency?]
+
+**Severity:** [How bad is it? 0-10 scale if pain]
+
+**Associated symptoms:** [Other symptoms occurring with this?]
+
+**Prior treatment and response:** [What has patient tried? Did it help?]
+
+**Functional impact:** [How does this affect daily activities?]
+
+**Review of Systems (pertinent to visit):**
+- Constitutional: [fever, chills, weight change, fatigue, night sweats]
+- [Other relevant systems based on chief complaint]
+- **Pertinent negatives:** [Important symptoms patient denies]
+
+---
+
+## O - OBJECTIVE
+
+### Vital Signs
+- Temperature: \_\_\_\_\_ °F (oral/axillary/tympanic)
+- Blood Pressure: \_\_\_\_\_/\_\_\_\_\_ mmHg
+- Heart Rate: \_\_\_\_\_ bpm
+- Respiratory Rate: \_\_\_\_\_ breaths/min
+- Oxygen Saturation: \_\_\_\_\_% on [room air / O2 at \_\_ L/min]
+- Height: \_\_\_\_\_ cm / inches
+- Weight: \_\_\_\_\_ kg / lbs
+- BMI: \_\_\_\_\_ kg/m²
+- Pain Score: \_\_\_/10
+
+### Physical Examination
+
+**General Appearance:**  
+[Well-appearing, no distress / ill-appearing / mild/moderate/severe distress]
+
+**HEENT:**  
+- Head: [Normocephalic, atraumatic]
+- Eyes: [PERRLA, EOMI, conjunctiva, sclera]
+- Ears: [TMs clear bilaterally, canals patent]
+- Nose: [Nares patent, no discharge]
+- Throat: [Oropharynx clear, no erythema or exudate, mucosa moist]
+
+**Neck:**  
+[Supple, no lymphadenopathy, no thyromegaly, no JVD, carotids 2+ without bruits]
+
+**Cardiovascular:**  
+[RRR, normal S1/S2, no murmurs/rubs/gallops] OR [describe abnormalities]  
+[Peripheral pulses: radial 2+/2+ bilaterally, dorsalis pedis 2+/2+ bilaterally]
+
+**Pulmonary:**  
+[Lungs clear to auscultation bilaterally, no wheezes/rales/rhonchi, normal work of breathing] OR [describe abnormalities]
+
+**Abdomen:**  
+[Soft, non-tender, non-distended, normoactive bowel sounds, no masses, no hepatosplenomegaly, no rebound/guarding]
+
+**Extremities:**  
+[No edema, no cyanosis, no clubbing, full range of motion, no joint swelling or tenderness]
+
+**Skin:**  
+[Warm and dry, no rashes, no lesions, normal turgor, capillary refill <2 sec]
+
+**Neurological:**  
+- Mental status: [Alert and oriented to person, place, time]
+- Cranial nerves: [II-XII intact] OR [specify abnormalities]
+- Motor: [5/5 strength all extremities, normal tone]
+- Sensory: [Intact to light touch and pinprick]
+- Reflexes: [2+ symmetric, downgoing Babinski]
+- Gait: [Normal / not assessed]
+- Coordination: [Finger-to-nose intact, rapid alternating movements normal]
+
+**Psychiatric:**  
+[Normal mood and affect, thought process logical and goal-directed, no SI/HI]
+
+### Laboratory Results (if applicable)
+| Test | Result | Reference Range | Flag |
+|------|--------|----------------|------|
+| [Test name] | [Value] [unit] | [Range] | [H/L/-] |
+
+### Imaging Results (if applicable)
+[Modality] ([Date]): [Key findings]
+
+### Other Diagnostic Tests
+[ECG, etc.]: [Results]
+
+---
+
+## A - ASSESSMENT
+
+### Problem List with Assessment
+
+**1. [Primary Problem/Diagnosis] ([ICD-10 code])**
+   - [Brief assessment: severity, stability, progress toward goals]
+   - [Relevant exam and lab findings supporting diagnosis]
+   - [Differential diagnosis if uncertain]
+
+**2. [Secondary Problem/Diagnosis] ([ICD-10 code])**
+   - [Assessment]
+
+**3. [Additional problems as needed]**
+
+### Overall Assessment
+[Summary statement about patient's overall status, response to treatment, trajectory]
+
+---
+
+## P - PLAN
+
+### Problem-Based Plan
+
+**1. [Primary Problem]**
+
+**Diagnostics:**
+- [Further tests, labs, imaging, consultations needed]
+- [Rationale for testing]
+
+**Therapeutics:**
+- [Medications:]
+  - [Drug name] [dose] [route] [frequency] x [duration]
+  - Indication: [Why prescribed]
+- [Procedures or interventions]
+- [Non-pharmacological interventions]
+
+**Monitoring:**
+- [What to monitor, how often]
+- [Parameters for follow-up labs or imaging]
+
+**Education:**
+- [Topics discussed with patient]
+- [Patient understanding verified]
+- [Written materials provided]
+
+**Follow-up:**
+- [When and where]
+- [Specific goals for follow-up visit]
+
+**Return Precautions:**
+- [When to seek urgent/emergency care]
+- [Warning signs discussed]
+
+**2. [Secondary Problem]**
+
+**Diagnostics:**
+- [Tests or studies]
+
+**Therapeutics:**
+- [Medications or interventions]
+
+**Monitoring:**
+- [Parameters to follow]
+
+**3. [Additional Problems]**
+[Plan for each problem]
+
+### Overall Plan Summary
+- Total new prescriptions: [number]
+- Referrals placed: [specialty, reason]
+- Follow-up appointment: [date/timeframe and with whom]
+- Patient verbalized understanding of plan: [Yes/No, questions answered]
+- Time spent: [Total time and time spent on counseling/coordination if relevant for billing]
+
+---
+
+## Billing Information (if applicable)
+
+**CPT Code:** [E/M code - 99201-99215 for office visits]
+
+**Level of Service Justification:**
+- History: [Problem focused / Expanded / Detailed / Comprehensive]
+- Exam: [Problem focused / Expanded / Detailed / Comprehensive]
+- Medical Decision Making: [Straightforward / Low / Moderate / High complexity]
+  - Number of diagnoses/management options: [Minimal / Limited / Multiple / Extensive]
+  - Amount of data to review: [Minimal / Limited / Moderate / Extensive]
+  - Risk: [Minimal / Low / Moderate / High]
+
+[OR if time-based:]
+- Total time: [minutes]
+- Time spent on counseling/coordination: [minutes] (>50% of visit)
+
+---
+
+## Signature
+
+[Provider name, credentials]  
+[Electronic signature or handwritten signature]  
+[Date and time of documentation]
+
+---
+
+## Notes for Using This Template
+
+**Best Practices:**
+- Document as soon as possible after encounter
+- Be specific and objective in observations
+- Avoid copy-forward errors
+- Review and update problem list
+- Sign and date all entries
+- Use standard abbreviations only
+
+**Billing Considerations:**
+- Document medical necessity
+- Match documentation level to billing code
+- For time-based billing, document total time and counseling time
+- Include relevant history, exam, and MDM elements
+
+**Legal Considerations:**
+- Document facts, not opinions
+- Quote patient when relevant
+- Document non-compliance objectively
+- Never alter records - use addendum for corrections
+- Ensure legibility
+
+**Customization:**
+- Adapt level of detail to setting (quick outpatient visit vs. complex hospital consultation)
+- Include or exclude sections as relevant
+- Follow institutional templates if required
+- Use problem-oriented approach consistently
+
+