/clinical-reports

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)

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