FinalSampleSOAPNoteFall2019.docx
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
SOAP NOTE
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 – Include three diagnoses
PLAN including education
o Plan:
Further testing
Medication
Education
Non-medication treatments
· Referrals
Follow-up visits
References
MSNSoapnoteRubric2744.docx
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