7.1 KiB
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
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