Basic SOAP Note Template - FM

Chief Complaint

The Chief Complaint is the primary symptom or issue that leads a patient to seek medical attention. It should be a brief and clear statement that describes the main symptom, problem, condition, diagnosis, physician-recommended follow-up, or any other reason for the patient's visit. Ensure the Chief Complaint is concise, focusing solely on the main reason for the visit.

History of Present Illness

[Presents a thorough interview focused on the patient's primary concerns or symptoms, including both current and past symptoms. Follow the mnemonic OPQRST AAA (onset, provocation, quality, radiation, severity, and time, associated symptoms, alleviating and aggravating factors) to assess the characteristics of the patient's symptoms related to CC. Include details such as timing, symptom frequency, bodily functions, sleep habits, impact on daily life, chronic disease management, immunization status, quantitative details, symptom onset, accidents or injuries, patient quotes, recent lab results, patient concerns, progress, conditions, diet and lifestyle, reproductive health, psychological symptoms, family information, diagnostic studies, and other important details. Maintain tense: Use past tense for past events, and present tense for events during the current encounter. Exclude treatment recommendations, discharge instructions, or the physician's plan for the patient.] (List items with bullet, and each item in a new line. )

Past Medical History

[Refers to a comprehensive record of all significant medical events, chronic diseases, and conditions a patient has experienced in the past. Include details such as hospitalizations, past surgeries, accidents or injuries, community resources, other specialists involved, recent travel, diagnosed conditions, and patient compliance with medical advice. Exclude current symptoms or complaints, which belong in the Review of Systems (ROS) section. Do not explicitly state no other items found.] (List items with bullet, and each item in a new line. )

Past Surgical History

[Provides a comprehensive account of the patient's previous surgical interventions. Include details such as type of surgery, body part involved, year performed, surgeon or facility, and complications. If the patient has no surgical history, this must be clearly stated.] (List items with bullet, and each item in a new line. )

Family History

[Document the health conditions and diseases affecting the patient's genetic relatives, including parents, siblings, and children. Exclude family surgical history. Include only explicitly stated information. Leave empty if no such items found.] (List items with bullet, and each item in a new line. )

Social History

[Document the patient's social history, including home environment, work environment, education, employment, social activities, drugs, sexuality, dietary habits, alcohol consumption, exercise routines, and relevant health information about the patient's spouse or partner. Include only explicitly stated information.] (List items with bullet, and each item in a new line. )

The Review of Systems

[Systematic review of symptoms the patient reports across all body systems. Include symptoms such as fever, chills, weight loss, blurry vision, hearing loss, rashes, chest pain, shortness of breath, nausea, urinary issues, joint pain, memory changes, mood changes, and easy bruising. Exclude any signs and exam findings observed by the physician. Focus on the patient's perspective and exclude duplication of symptoms already discussed in the HPI.] (List items with bullet, and each item in a new line. )

Current Medications

[Document the list of medications being taken by the patient, including over-the-counter medications and supplements. Include details such as medication name, dosage, frequency, and route. Document adherence, management, and any side effects discussed. Exclude new medications prescribed during the current encounter.] (List items with bullet, and each item in a new line. )

Allergies

[Document the patient's known allergies, including hypersensitivity to medications, foods, or environmental factors. Include explicit confirmation of no known allergies if stated. Exclude allergy testing conducted during the encounter.] (List items with bullet, and each item in a new line. )

Vital Signs

[List the patient's vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and pain level. Include results of questionnaires or scores of self-administered and physician-administered tests if available.]

Physical Examination

[Document objective findings from the healthcare provider's hands-on examination. Include findings per body system, using correct examination terminology. Include height, weight, and any telehealth documentation if applicable.] (List items with bullet, and each item in a new line. )

Investigations

[Document laboratory test results and results of questionnaires or scores of self-administered and physician-administered tests. Use formal medical terminology.] (List items with bullet, and each item in a new line. )

Problem

[List the doctor's diagnosis based on the patient's symptoms, self-reported changes, and examination findings related to the chief complaints and current encounter. Exclude past medical history diagnoses irrelevant to the presenting complaint.] (List items with bullet, and each item in a new line. )

Differential Diagnosis

[Summarize potential diagnoses based on the patient's symptoms, medical history, physical examination findings, and diagnostic test results. Include a brief explanation for each diagnosis. Exclude repetitive diagnoses already in the Problem section.] (List items with bullet, and each item in a new line. )

Plan

[Provide a comprehensive plan for the patient, including test orders, medication details, referrals, follow-ups, lifestyle modifications, external resources, patient education, and monitoring targets. Use past tense for interventions already performed and present tense for ongoing or future actions.] (List items with bullet, and each item in a new line. )

Plan

[Provide a comprehensive plan for the patient, including test orders, medication details, referrals, follow-ups, lifestyle modifications, external resources, patient education, and monitoring targets. Use past tense for interventions already performed and present tense for ongoing or future actions.] (List items with bullet, and each item in a new line. )

Surgery Discussion

[Document the purpose of the surgery, risks and complications, anesthesia details, and alternatives if explicitly mentioned.]