Basic SOAP Note Template - EM

Chief Complaint

Emergency Medicine SOAP Note Template

History of Present Illness

[Write a comprehensive, chronological account of the patient's immediate concerns or symptoms. Use the OPQRST AAA mnemonic: onset, provocation, quality, radiation, severity, timing, associated symptoms, alleviating, and aggravating factors. Include details of timing, sequence, frequency, patterns, recent lab results, location, quantitative details, quality, reproductive health, psychological/cognitive symptoms, family input, pertinent negatives, significant past medical history, severity, alleviating/aggravating factors, context (travel, diet, lifestyle, exposures), immunization/health factors, and any other relevant details. Exclude treatment recommendations, discharge instructions, physician's plan, and physical exam findings. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Past Medical History

[Provide a comprehensive record of all significant past medical events, chronic diseases, and conditions, including onset, progression, management, and outcomes. Include hospitalizations, ED visits, past treatments, compliance with medical advice, missed appointments, and relevant lifestyle factors. Only include information explicitly stated. Do not mention missing or unaddressed information. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Past Surgical History

[List all previous surgeries, specifying type, body part, year, surgeon or facility if known, and any complications. If no surgical history, clearly state so. Mark unknown fields as 'unknown' if details are not available. Only include information explicitly stated. Do not mention missing or unaddressed information. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Allergies

[Document all known allergies to medications, foods, environmental agents, anesthetics, adhesives/tape, and latex. Include explicit confirmation of no known allergies if stated. Exclude allergy testing performed during the encounter. Only include information explicitly stated. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Family History

[Document health conditions and diseases affecting the patient's genetic relatives (parents, siblings, children), including hereditary or environmental factors. Do not include family surgical history. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Social History

[Document home environment, work, education, employment, social activities, drug use, sexuality, dietary habits, alcohol, exercise, and relevant partner health information if provided. Only include information explicitly stated. Do not mention absence of information. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

The Review of Systems

[List the patient's reported symptoms by organ system, based on systematic physician questioning. Include both positive and negative findings as stated. Capture the patient's perspective, feelings, fears, and expectations. Do not include physical exam findings or duplicate HPI content. Only include systems and symptoms explicitly discussed. Write as a list with each symptom or system on a new line, without prefixes or bullet points. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Medications

[List all current medications, including over-the-counter and supplements. For each, include name, dosage, frequency, and route. Include birth control if applicable. Document adherence, recall, attitudes, and any inability to recall medications. Explicitly document discussed side effects, education provided, and patient understanding. Do not include new medications prescribed during this encounter. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Vital Signs

[List the patient's vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, pain level) and any assessment scores (e.g., PHQ-9, GAD-7) if reported. Each item should be on a new line, without prefixes or bullet points. Only include information explicitly stated. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.]

Physical Examination

[Provide a narrative description of objective findings from the physician's examination. Include general, ENT, chest, CVS, abdomen, neuro, MSK, skin, ECG, and POCUS findings as relevant. Use formal medical terminology and complete sentences. Detail examination techniques and findings. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Investigations

[Enter laboratory test results and results of questionnaires or assessment scales (e.g., Epworth, PHQ-9, GAD-7, MMSE, VAS). Compose each result as a complete sentence using formal medical terminology. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Summary Statement

[Write 1-2 sentences summarizing the reason for the ED visit, integrating key historical details, pertinent physical exam findings, and initial diagnostic impressions. Be concise and focused, providing context and risk stratification. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.]

Differential Diagnosis

[List potential diagnoses explaining the patient's symptoms and findings. For each acute issue, provide an explanation and supporting evidence. Order by likelihood, severity, and urgency. If no diagnostic tests or investigations are mentioned, leave this section null. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Plan

[List the specific actions and interventions for managing the patient's acute condition(s), including diagnostic testing, therapeutic interventions, procedures, specialist referrals, patient education, and disposition. Each item should be on a new line, without prefixes or bullet points. Only include information explicitly stated. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Plan

[List the specific actions and interventions for managing the patient's acute condition(s), including diagnostic testing, therapeutic interventions, procedures, specialist referrals, patient education, and disposition. Each item should be on a new line, without prefixes or bullet points. Only include information explicitly stated. If not mentioned, leave this section null. Refer to the patient by name if mentioned, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Reassessment Note

[Write a narrative documenting the ongoing evaluation after initial assessment and intervention. Include clinical status update, response to treatment, new findings, ongoing monitoring, interventions/adjustments, patient's subjective feedback, and plan for further care and follow-up. Only include information explicitly stated. Refer to the patient by name if mentioned, otherwise use 'The patient'.]