SOAP Note Template — Universal Medical Documentation
The SOAP Note Template is the gold standard for medical documentation used by physicians, nurse practitioners, and physician assistants across all specialties. SOAP (Subjective, Objective, Assessment, Plan) provides a systematic framework for documenting patient encounters that supports clinical decision-making, care continuity, and appropriate billing. This universal template includes structured sections for subjective findings (chief complaint, HPI, ROS, PMH, medications, allergies), objective data (vital signs, physical examination, diagnostic results), clinical assessment with differential diagnosis, and detailed treatment plan. The SOAP format is recognized by all healthcare systems and supports E/M coding (99202-99215) while ensuring comprehensive documentation. Ideal for outpatient visits, inpatient rounds, urgent care encounters, specialty consultations, and telehealth appointments across all medical specialties.
Template
Subjective
Chief Complaint
[Primary reason for visit in patient's own words]
Duration: [Onset, timeline]
History of Present Illness (HPI)
Onset: [When symptoms began]
Location: [Where symptoms are located]
Duration: [How long symptoms last]
Character: [Quality/nature of symptoms]
Aggravating factors: [What makes it worse]
Alleviating factors: [What makes it better]
Radiation: [Does it spread]
Timing: [Constant, intermittent, pattern]
Severity: [X]/10
Associated symptoms: [Related symptoms]
Pertinent negatives: [Important symptoms NOT present]
Review of Systems
Constitutional: [ ] Fever [ ] Chills [ ] Fatigue [ ] Weight change
HEENT: [ ] Headache [ ] Vision changes [ ] Sore throat
Cardiovascular: [ ] Chest pain [ ] Palpitations [ ] Edema
Respiratory: [ ] Cough [ ] Dyspnea [ ] Wheezing
GI: [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Abdominal pain
GU: [ ] Dysuria [ ] Frequency [ ] Hematuria
MSK: [ ] Joint pain [ ] Back pain [ ] Weakness
Neuro: [ ] Dizziness [ ] Numbness [ ] Headache
Psych: [ ] Depression [ ] Anxiety [ ] Sleep disturbance
All other systems reviewed and negative unless noted above.
Past Medical History
Active conditions: [List]
Surgical history: [List with dates]
Hospitalizations: [Recent/relevant]
Medications
[Current medications with doses]
Allergies
[Drug allergies with reactions] / NKDA
Social History
Tobacco: Current / Former / Never
Alcohol: [Use pattern]
Occupation: [Relevant exposures]
Living situation: [Relevant context]
Family History
[Relevant family history]
---
Objective
Vital Signs
BP: [X/X] mmHg
HR: [X] bpm
RR: [X] breaths/min
Temp: [X]°F / [X]°C
SpO2: [X]% on room air
Weight: [X] kg / lbs
BMI: [X]
Physical Examination
General: [Alert, oriented, appearance, distress level] HEENT:- Head: Normocephalic, atraumatic
- Eyes: PERRL, EOMI, conjunctivae clear
- Ears: TMs clear bilaterally
- Nose: [Findings]
- Throat: Oropharynx clear, no erythema or exudate
Diagnostic Results
Laboratory: [Relevant results]
Imaging: [Relevant results]
Other: [POC testing, EKG, etc.]
---
Assessment
1) [Primary diagnosis] — [Severity/acuity]
Clinical reasoning: [Supporting evidence from S and O]
2) [Secondary diagnosis if applicable]
Differential diagnoses considered:
- [Alternative diagnosis 1]
- [Alternative diagnosis 2]
- [Alternative diagnosis 3]
---
Plan
For Problem 1: [Primary diagnosis]
- Diagnostic workup: [Labs, imaging, referrals]
- Treatment: [Medications, procedures]
- Patient education: [Key teaching points]
For Problem 2: [If applicable]
- [Management plan]
Medications
- New: [Medication, dose, frequency, duration]
- Continued: [Current medications]
- Discontinued: [Medications stopped, reason]
Follow-up
- Return: [Timeframe] for [reason]
- Sooner if: [Warning signs requiring earlier evaluation]
- Referrals: [Specialty, reason]
Patient Education
Diagnosis explained in understandable terms. Treatment plan reviewed. Warning signs discussed. Patient verbalized understanding and agreement with plan.
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