Soap Note Template

# 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 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