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Soap Note Template 01

This document provides a template for writing a SOAP note, which includes 4 sections - Subjective, Objective, Assessment, and Plan. The Subjective section includes the patient's history, past medical history, and current medications. The Objective section focuses on vital signs, physical exam findings, and laboratory results. The Assessment section states the main problem and provides differential diagnoses. Finally, the Plan section develops diagnostic and treatment plans for each diagnosis and addresses follow up care.

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Matthew Marr
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1K views1 page

Soap Note Template 01

This document provides a template for writing a SOAP note, which includes 4 sections - Subjective, Objective, Assessment, and Plan. The Subjective section includes the patient's history, past medical history, and current medications. The Objective section focuses on vital signs, physical exam findings, and laboratory results. The Assessment section states the main problem and provides differential diagnoses. Finally, the Plan section develops diagnostic and treatment plans for each diagnosis and addresses follow up care.

Uploaded by

Matthew Marr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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SOAP Note Template

Subjective – The “history” section

HPI: include symptom dimensions, chronological narrative of patient’s complains,


information obtained from other sources (always identify source if not the patient).

Pertinent past medical history.

Pertinent review of systems, for example, “Patient has not had any stiffness or loss
of motion of other joints.”

Current medications (list with daily dosages).

Objective – The physical exam and laboratory data section

Vital signs including oxygen saturation when indicated.

Focuses physical exam.

All pertinent labs, x-rays, etc. completed at the visit.

Assessment/Problem List – Your assessment of the patient’s problems

Assessment: A one sentence description of the patient and major problem

Problem list: A numerical list of problems identified

All listed problems need to be supported by findings in subjective and objective areas
above. Try to take the assessment of the major problem to the highest level of
diagnosis that you can, for example, “low back sprain caused by radiculitis involving
th
left 5 LS nerve root.”
Provide at least 2 differential diagnoses for the major new problem identified in your
note.

Plan – Your plan for the patient based on the problems you’ve identified

Develop a diagnostic and treatment plan for each differential diagnosis.

Your diagnostic plan may include tests, procedures, other laboratory studies,
consultations, etc.

Your treatment plan should include: patient education, pharmacotherapy if any,


other therapeutic procedures. You must also address plans for follow-up (next
scheduled visit, etc.).

Also see your Bates Guide to Physical Examination for excellent examples of
complete H & P and SOAP note formats.

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