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SOAP Note Template

S: Subjective

Information the patient or patient representative told you

Initials: T.J.	Age: Click or tap here to enter text.	Gender: Female
Height	Weight	BP	HR	RR	Temp	SPO2	Pain Rating	Allergies (and reaction)
170cm	90kg	142/80	86	19	101.1F	99%	7/10	Medication: Penicillin (rash/hives) Food: N/A Environment: Cats (itchy, eye redness, watery eyes)
History of Present Illness (HPI)
Chief Complaint (CC)	Infected Right foot pain	CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
O nset	1 week ago
L ocation	Ball of Right foot but also feels some pain in whole foot
D uration	1 week ago. Pain worse 2 days ago, current pain level 7/10
C haracteristics	Sharp and throbbing
A ggravating Factors	Walking and weight bearing
R elieving Factors	Tramadol and no weight bearing
T reatment	Taking pain medication, irrigate the wound, and apply a dry dressing
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication (Rx, OTC, or Homeopathic)	Dosage	Frequency	Length of Time Used	Reason for Use
Tramadol	50mg PO	PRN	1 week	Right foot pain
Neosporin	N/A	PRN	1 week	Right foot laceration
Proventil	90mcg/spray	Q4H PRN 2-3 puffs	25 years	asthma
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Diabetes, Asthma diagnosed at a young age, hypertension, tetanus shot (last year), up to date with immunizations, heavy menstrual periods, ER admit last week
Social History (Soc Hx) – Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Drugs: History of marijuana use. Stopped at age 20 or 21 due to asthma exacerbation Drinking: Socially drinks once or twice a week Smoking/Tobacco use: No Occupation: College student Family status: Lives with mother and younger sister
Family History (Fam Hx) – Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Father: Deceased due to a car accident, hypertension, type 2 diabetes, high cholesterol Mother: hypertension, high cholesterol Sister: asthma Brother: N/A Paternal grandfather: hypertension, high cholesterol, diabetes, colon cancer Paternal grandmother: hypertension, high cholesterol Maternal grandfather: hypertension, high cholesterol, deceased due to a heart attack Maternal grandmother: hypertension, high cholesterol, deceased due to stroke

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.

Constitutional

If patient denies all symptoms for this system, check here: ☐

Skin

If patient denies all symptoms for this system, check here: ☐

HEENT

If patient denies all symptoms for this system, check here: ☐

☒Fatigue Click or tap here to enter text.

☐Weakness Click or tap here to enter text.

☒Fever/Chills Click or tap here to enter text.

☐Weight Gain

☒Weight Loss 10-lb weight loss

☒Trouble Sleeping Click or tap here to enter text.

☒Night Sweats Click or tap here to enter text.

☒Other:

Wakes up with hot flashes

☐Itching Click or tap here to enter text.

☐Rashes Click or tap here to enter text.

☐Nail Changes Click or tap here to enter text.

☒Skin Color Changes states skin around neck is getting darker

☐Other:

Click or tap here to enter text.

☐Diplopia Click or tap here to enter text.

☐Eye Pain Click or tap here to enter text.

☐Eye redness Click or tap here to enter text.

☒Vision changes Click or tap here to enter text.

☐Photophobia Click or tap here to enter text.

☐Eye discharge Click or tap here to enter text.

☐Earache Click or tap here to enter text.

☐Tinnitus Click or tap here to enter text.

☐Epistaxis Click or tap here to enter text.

☐Vertigo Click or tap here to enter text.

☐Hearing Changes Click or tap here to enter text.

☐Hoarseness Click or tap here to enter text.

☐Oral Ulcers Click or tap here to enter text.

☐Sore Throat Click or tap here to enter text.

☐Congestion Click or tap here to enter text.

☐Rhinorrhea Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

Respiratory

If patient denies all symptoms for this system, check here: ☐

Neuro

If patient denies all symptoms for this system, check here: ☒

Cardiac and Peripheral Vascular

If patient denies all symptoms for this system, check here: ☐

☐Cough Click or tap here to enter text.

☐Hemoptysis Click or tap here to enter text.

☐Dyspnea Click or tap here to enter text.

☒Wheezing asthma symptoms

☐Pain on Inspiration Click or tap here to enter text.

☐Sputum Production

Choose an item.

☐Other: Click or tap here to enter text.

☐Syncope or Lightheadedness Click or tap here to enter text.

☐Headache Click or tap here to enter text.

☐Numbness Click or tap here to enter text.

☐Tingling Click or tap here to enter text.

☐Sensation Changes

Choose an item.

☐Speech Deficits Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Chest pain Click or tap here to enter text.

☒SOB due to asthma

☒Exercise Intolerance due to asthma

☐Orthopnea Click or tap here to enter text.

☐Edema Click or tap here to enter text.

☐Murmurs Click or tap here to enter text.

☐Palpitations Click or tap here to enter text.

☐Faintness Click or tap here to enter text.

☐Claudications Click or tap here to enter text.

☐PND Click or tap here to enter text.

☐Other: Click or tap here to enter text.

MSK

If patient denies all symptoms for this system, check here: ☐

PSYCH

If patient denies all symptoms for this system, check here: ☐

☒Pain (right foot)

☐Stiffness Click or tap here to enter text.

☐Crepitus Click or tap here to enter text.

☒Swelling (right foot)

☐Limited ROM Choose an item.

☒Redness (Right foot)

☐Misalignment Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Nausea/Vomiting Click or tap here to enter text.

☐Dysphasia Click or tap here to enter text.

☐Diarrhea Click or tap here to enter text.

☒Appetite Change (hungrier than usual)

☐Heartburn Click or tap here to enter text.

☐Blood in Stool Click or tap here to enter text.

☐Abdominal Pain Click or tap here to enter text.

☐Excessive Flatus Click or tap here to enter text.

☐Food Intolerance Click or tap here to enter text.

☐Rectal Bleeding Click or tap here to enter text.

☐Other:

☐Urgency Click or tap here to enter text.

☐Dysuria Click or tap here to enter text.

☐Burning Click or tap here to enter text.

☐Hematuria Click or tap here to enter text.

☒Polyuria Click or tap here to enter text.

☒Nocturia Click or tap here to enter text.

☐Incontinence Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☒Stress (school and work related)

☒Anxiety (when father passed away)

☐Depression Click or tap here to enter text.

☐Suicidal/Homicidal Ideation Click or tap here to enter text.

☐Memory Deficits Click or tap here to enter text.

☐Mood Changes Click or tap here to enter text.

☐Trouble Concentrating Click or tap here to enter text.

☐Other: Click or tap here to enter text.

GYN

If patient denies all symptoms for this system, check here: ☐

Hematology/Lymphatics

If patient denies all symptoms for this system, check here: ☒

Endocrine

If patient denies all symptoms for this system, check here: ☐

☐Rash Click or tap here to enter text.

☐Discharge Click or tap here to enter text.

☐Itching Click or tap here to enter text.

☒Irregular Menses (6 periods a year)

☐Dysmenorrhea Click or tap here to enter text.

☐Foul Odor Click or tap here to enter text.

☐Amenorrhea Click or tap here to enter text.

☐LMP: Click or tap here to enter text.

☐Contraception Click or tap here to enter text.

☐Other:Click or tap here to enter text.

☐Anemia Click or tap here to enter text.

☐ Easy bruising/bleeding Click or tap here to enter text.

☐ Past Transfusions Click or tap here to enter text.

☐ Enlarged/Tender lymph node(s) Click or tap here to enter text.

☐ Blood or lymph disorder Click or tap here to enter text.

☐ Other Click or tap here to enter text.

☐ Abnormal growth Click or tap here to enter text.

☒ Increased appetite Click or tap here to enter text.

☒ Increased thirst Click or tap here to enter text.

☐ Thyroid disorder Click or tap here to enter text.

☐ Heat/cold intolerance Click or tap here to enter text.

☐ Excessive sweating Click or tap here to enter text.

☒ Diabetes Click or tap here to enter text.

☐ Other Click or tap here to enter text.

O: Objective

Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.

Body System

Positive Findings

Negative Findings

General

N/A

N/A

Skin

Wound found on the ball of right foot. Redness, swelling, and warm to touch around the area. White color drainage at the site of injury. Wound measurement: 2cm x 1.5 cm, 2.5 mm deep

No odor noted

HEENT

N/A

Respiratory

Neuro

Cardiovascular

Musculoskeletal

Gastrointestinal

Genitourinary

Psychiatric

Gynecological

Problem List
Acute pain on Right foot	6. Obesity	11. Click or tap here to enter text.
2. Asthma	7. Oligomenorrhea	12. Click or tap here to enter text.
3. Uncontrolled diabetes	8. Menorrhagia	13. Click or tap here to enter text.
4. .	9. Headaches	14. Click or tap here to enter text.
5. Obesity	10. Click or tap here to enter text.	15. Click or tap here to enter text.

A: Assessment

Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.

Diagnosis	ICD-10 Code	Pertinent Findings
	Click or tap here to enter text.	Click or tap here to enter text.
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P: Plan

Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.

Diagnostics: List tests you will order this visit
Test	Rationale/Citation
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Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent.
Drug	Dosage	Length of Treatment	Rationale/Citation
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Referral/Consults:
Click or tap here to enter text.	Rationale/Citation	Click or tap here to enter text.
Education:
Click or tap here to enter text.	Rationale/Citation	Click or tap here to enter text.
Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Click or tap here to enter text.	Rationale/Citation	Click or tap here to enter text.
References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting.
Click or tap here to enter text.

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SOAP Note Template

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