Basic SOAP Note Template - IM

Chief Complaint

Comprehensive Adult Internal Medicine SOAP Note Template

History of Present Illness

[Write a detailed, chronological narrative of the patient's current health concerns and associated symptoms, using the OPQRST AAA mnemonic (onset, provocation, quality, radiation, severity, time, associated symptoms, alleviating and aggravating factors). Include timing, frequency, sequence, pertinent negatives, impact on daily life, chronic disease management, recent hospitalizations, immunization/immunosuppression factors, past diagnostic outcomes, psychological/cognitive aspects, family contributions, and any changes since last visit. For females, include emerging autoimmune or pregnancy-related factors. For Long COVID, detail onset, progression, and impact. Include previous investigations/treatments and their outcomes. Do not repeat information in the Review of Systems. Use 'He/him/His' pronouns for the patient. Separate each item with a newline, no prefixes.] (List items with bullet, and each item in a new line. )

Past Medical History

[Provide a comprehensive, chronological record of all significant past medical events, chronic diseases, and conditions, including onset, progression, treatments, outcomes, and compliance with medical advice. Include hospitalizations, ED visits, surgeries, accidents/injuries, community resources, referrals, other specialists, recent travel, and formally diagnosed conditions. Explicitly document compliance or non-compliance with treatments and missed appointments, including impact on health. Only include information explicitly stated. Do not include current symptoms or complaints. Use 'He/him/His' pronouns for 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. For specialty encounters, include relevant surgeries. Mark unknown fields as 'unknown' if details are not recalled. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Family History

[List short phrases describing diseases and health conditions of the patient's blood relatives (parents, siblings, children), including health status, cause of death, hereditary conditions, common familial conditions, ethnic background, age/health of relatives, and patterns of illness. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Social History

[Write a narrative paragraph summarizing the patient's social history, including occupation, marital status, living situation, functional status, smoking/alcohol/drug use, exercise, dietary habits, and sexual history. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

The Review of Systems

[List symptoms reported by the patient across all body systems, including both positive and negative findings, as directly stated. Do not include physician-observed signs or exam findings. Focus on systematic questions asked by the physician and the patient's responses, including their perspective, fears, and expectations. Do not repeat symptoms already discussed in the HPI. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Current Medications

[List all current medications, including over-the-counter and supplements, with name, dosage, frequency, and route. Include birth control if applicable. Explicitly document adherence, recall, attitudes, and any inability to recall medications. Include all discussed medication side effects, education provided, and patient understanding or concerns. Do not include new medications prescribed during this encounter. Only include information explicitly stated. Use 'He/him/His' pronouns for 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, as disclosed by the patient. Include explicit confirmation of no known allergies if stated. Do not include allergy testing performed during the encounter. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Vital Signs

[List all reported vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, pain level) and any assessment scores (e.g., PHQ-9, GAD-7) as stated. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.]

Investigations

[Enter laboratory and diagnostic test results, including blood/urine analyses and questionnaire scores (e.g., Epworth, PHQ-9, GAD-7, MMSE, VAS). Write each key result as a complete sentence using formal medical terminology. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Impression

[Write a brief 1-2 sentence summary of the clinical impression, including the most relevant subjective, objective, and test result information. Include positive and negative findings. If the visit is for preventive care, include this in the summary. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.]

Problem

[List the main diagnoses or health issues related to the chief complaint and current encounter, in order of importance. Use ICD-9 codes (or ICD-10-CA for COVID-19-related diagnoses) after each diagnosis. Include detailed descriptions of new or changing symptoms and pertinent physical findings. Do not include irrelevant chronic conditions or past medical history. Medication refill is not a diagnosis; infer the underlying condition. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Pre-Operative Assessment

[If the visit is for pre-operative assessment, write a comprehensive narrative summarizing the patient's medical and surgical history, medications, allergies, family/social history, physical exam findings, diagnostic test results, risk stratification, optimization strategies, patient education, and consent. If not a pre-op visit, enter null. Use 'He/him/His' pronouns for the patient.]

Differential Diagnosis

[List potential alternative diagnoses not already included in the Problem section, each followed by a brief explanation based on symptoms, history, exam, or test findings. Exclude overlap with the Problem section. If no differential diagnosis was discussed, enter null. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Plan

[List all actions taken and next steps for the patient, using past tense for completed interventions and present tense for ongoing/future actions. Include test orders, medication details (with dosages/frequencies), therapy referrals, lifestyle modifications, referrals (with specialist name, specialty, reason, urgency), follow-up details (date/time, purpose, preparation), alternative plans, external resources (with contact info), medication side effect education, patient education/counseling (only if explicitly provided), monitoring targets, and rationale for therapies. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )

Plan

[List all actions taken and next steps for the patient, using past tense for completed interventions and present tense for ongoing/future actions. Include test orders, medication details (with dosages/frequencies), therapy referrals, lifestyle modifications, referrals (with specialist name, specialty, reason, urgency), follow-up details (date/time, purpose, preparation), alternative plans, external resources (with contact info), medication side effect education, patient education/counseling (only if explicitly provided), monitoring targets, and rationale for therapies. Separate each item with a newline, no prefixes. Only include information explicitly stated. Use 'He/him/His' pronouns for the patient.] (List items with bullet, and each item in a new line. )