SOAP Note Template
Encounter date: ________________________
Affected person Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Purpose for Looking for Well being Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergy symptoms(Drug/Meals/Latex/Environmental/Natural): ___________________________________
Present notion of Well being: Glorious Good Honest Poor
Previous Medical Historical past
• Main/Persistent Illnesses____________________________________________________
• Trauma/Damage ___________________________________________________________
• Hospitalizations __________________________________________________________
Previous Surgical History___________________________________________________________
Drugs: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Household Historical past: ____________________________________________________________
Social historical past:
Lives: Single household Home/Condominium/ with stairs: ___________ Marital Standing:________ Employment Standing: ______ Present/Earlier occupation sort: _________________
Publicity to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Exercise: ____ Contraception Use: ____________
Household Composition: Household/Mom/Father/Alone: _____________________________
Well being Upkeep
Screening Exams: Mammogram, PSA, Colonoscopy, Pap Smear, And so forth _____
Exposures:
Immunization HX:
Assessment of Programs:
Common:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/feminine genital:
GU:
Neuro:
Musculoskeletal:
Exercise & Train:
Psychosocial:
Derm:
Diet:
Sleep/Relaxation:
LMP:
STI Hx:
Bodily Examination
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
Common:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/feminine genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Plan:
Differential Diagnoses
1.
2.
three.
Principal Diagnoses
1.
2.
Plan
Prognosis
Diagnostic Testing:
Pharmacological Remedy:
Schooling:
Referrals:
Observe-up:
Anticipatory Steerage:
Prognosis
Diagnostic Testing:
Pharmacological Remedy:
Schooling:
Referrals:
Observe-up:
Anticipatory Steerage:
Signature (with applicable credentials): __________________________________________
Cite present evidenced based mostly guideline(s) used to information care (Obligatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Affected person Title: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: _____________________
Template for SOAP Notes
Initials of the affected person: Age: Race: Ethnicity Gender: M/F/Transgender Gender: M/F/Transgender Gender: M/F/Transgender Gender: M/F/
Purpose for Looking for Well being Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergy symptoms(Drug/Meals/Latex/Environmental/Natural): ___________________________________
Present notion of Well being: Glorious Good Honest Poor
Previous Medical Historical past
• Main/Persistent Illnesses____________________________________________________
• Trauma/Damage ___________________________________________________________
• Hospitalizations __________________________________________________________
Previous Surgical History___________________________________________________________
Drugs: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Household Historical past: ____________________________________________________________
Social historical past:
Lives: Single household Home/Condominium/ with stairs: ___________ Marital Standing:________ Employment Standing: ______ Present/Earlier occupation sort: _________________
Publicity to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Exercise: ____ Contraception Use: ____________
Household Composition: Household/Mom/Father/Alone: _____________________________
Well being Upkeep
Screening Exams: Mammogram, PSA, Colonoscopy, Pap Smear, And so forth _____
Exposures:
Immunization HX:
Assessment of Programs:
Common:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/feminine genital:
GU:
Neuro:
Musculoskeletal:
Exercise & Train:
Psychosocial
_______________________________________
