SOAP Note Template
Subjective
Patient: Initials, Age, Sex
Chief Complaint: This is in the patient’s own words – short (2 or 3 words).
History of Present Illness: Use your OPQRST here for a detailed description.
Past Medical History: List the medical conditions, with year of diagnosis.
Past Surgical History: List past surgeries, with year.
Medications: List the medications and what they are prescribed for (diagnosis).
Allergies: List allergy and reaction for medication and food allergies and environmental allergies. Pollen allergies belong in the past medical history as a medical condition (allergic rhinitis).
Immunizations: List each one and date; for pediatrics, include childhood schedule; for adults, include age-appropriate vaccines (e.g., Tdap, pneumonia, shingles, influenza, COVID).
Family History: List each family member, with age and medical conditions, cause of death if applicable, and age at death for grandparents, parents, siblings, any offspring of patient.
Social History/Risk Factors: Living arrangements, financial concerns, alcohol, tobacco use, illicit substances, sexual hx, domestic violence risk, etc.
Review of Systems:
List each system with pertinent positives and negatives:
General: (-) fevers, (-) chills, (-) unintentional weight loss/gain or changes in appetite, (-) changes in exercise ability, (-) fatigue.
Head: (-) headache, (-) dizziness, (-) sinus pressure (frontal and maxillary).
Eyes: (-) changes in vision, (-) blurred vision, (-) double vision, (-) floaters. Last eye exam: (-) redness, (-) drainage (-) watery eyes.
Ears: (-) changes or difficulty in hearing, (-) ear pain, (-) drainage.
Nose: (-) difficulty smelling, (-) runny nose, (-) congestion, (-) epistaxis.
Mouth/Throat: (-) problems swallowing, (-) difficulty eating/chewing foods, (-) sores or lesions, (+) postnasal drip. Last dental exam:
Neck: (-) stiffness, (-) pain, (-) left neck nodule, (-) reflux.
Respiratory: (-) difficulty breathing, (-) shortness of breath, (-) cough (-) dyspnea, (-) wheezing.
Cardiovascular: (-) chest pain, (-) abnormal heart beats, (-) skipped beats, (-) fluttering, (-) shortness of breath with exertion.
GI: (-) nausea/vomiting, (-) heartburn, (-) acid reflux, (-) pain with defecation, (-) rectal bleeding, (-) hemorrhoids. Bowel movement. (-) constipation, (-) diarrhea.
GU: (-) difficult urination, (-) painful urination, (-) urinary frequency.
GYN: (if applicable) (-) abnormal menstrual bleeding, (-) vaginal discharge/odor, last menstrual period (LMP).
Musculoskeletal: (-) painful bilateral legs, (-) pain joints, (-) problems with range of motion, (-) stiffness, (-) backaches.
Neurological: (-) weakness, (-) dizziness, (-) blurred vision, (-) unsteady gait, (-) changes in memory, (-) changes in mood.
Psychiatric: (-) depression, (-) anxiety, (-) sleep disturbances, (-) nervousness, (-) suicidal ideation, (-) suicidal attempts.
Skin: (-) changes in skin, (-) rashes, (-) lesions.
Endocrine: (-) weight loss or weight gain, (-) excessive sweating, (-) hair thinning/loss, (-) hot or cold intolerance, (-) excessive thirst.
Hem/Lymph: (-) bruising or getting sick easily, (-) excessive healing time, (-) anemia.
Objective
Vital Signs: Whether sitting or standing Temp, BP, Pulse, Respiratory Rate, Height, Weight, BMI, O2 sats if applicable.
General: See documentation findings for each system in the Bates’ Guide to Physical Examination and History Taking textbook and you can make changes/additions to this to be reflective of your exam.
Neurological:
HEENT:
Neck:
Lymph Nodes:
Respiratory:
Cardiovascular:
GI:
Back:
Musculoskeletal:
Skin:
Psychiatric (affect, mood)
Assessment
This is where you list your actual diagnosis, ICD codes, and differential diagnosis.
Plan
This is your plan for the patient, including treatment, labs, radiologic studies, medications, etc. Please utilize CareOnPoint and the Bates’ Guide to Physical Examination and History Taking textbook for this. Always include a follow-up plan, even if it is just “as needed.”
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