Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = Onset of symptom (acute/gradual)
L= Location
D= Duration (recent/chronic)
C= Character
A= Associated symptoms/aggravating factors
R= Relieving factors
T= Treatments previously tried—response? Why discontinued?
S= Severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e., 34-year-old AA male). You must include the seven attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADLs and IADLs if applicable, and exercise and eating habits.
Immunization History: Include last Tdap, flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head to toe, include each system that covers the chief complaint, history of present illness, and history (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history if you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, height, weight, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, affect, and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN:
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, X-rays, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies, such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
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