SOAP NOTE

Patient Initials:

Pt. Encounter Number:

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC:

HPI: Describe the course of the patient’s illness:

Onset:

Location:

Duration:

Characteristics:

Aggravating Factors:

Relieving Factors:

Treatment:

Current Medications:

PMH

Medication Intolerances:

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:

Social History:

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

PHYSICAL EXAMINATION

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

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