Concise SOAP template

Subjective

[Write Subjective findings in an very concise bullet point format. (Write in a list form). Use abbreviations and medical shorthand wherever possible. Do not use complete sentences. Only include essential information] For example: Fever 5th day Today 37.1-37.3, last night 38- down after tylenol (Have each concern as a numbered list format) Example: 1. [Problem 1]: - [Symptoms and onset] - [Relevant past medical or family history. If not mentioned don't write] 2. [Problem 2]: - [Symptoms and onset] - [Relevant past medical or family history. If not mentioned don't write]

Chief Complaint

Medical Note Template

Subjective

[Write Subjective findings in an very concise bullet point format. (Write in a list form). Use abbreviations and medical shorthand wherever possible. Do not use complete sentences. Only include essential information] For example: Fever 5th day Today 37.1-37.3, last night 38- down after tylenol (Have each concern as a numbered list format) Example: 1. [Problem 1]: - [Symptoms and onset] - [Relevant past medical or family history. If not mentioned don't write] 2. [Problem 2]: - [Symptoms and onset] - [Relevant past medical or family history. If not mentioned don't write]

H&N

[Include concise bullet points of head and neck examination findings, using medical shorthand and abbreviations. If not examined do not write out.] **CV:**[Include concise bullet points of cardiovascular examination findings, using medical shorthand and abbreviations.] **Lungs:**[Include concise bullet points of lung examination findings, using medical shorthand and abbreviations.] **Abdo/Pelvis:**[Include concise bullet points of abdominal and pelvic examination findings, using medical shorthand and abbreviations.] **Extremities:**[Include concise bullet points of extremities examination findings, using medical shorthand and abbreviations.] **Neuro:**[Include concise bullet points of neurological examination findings, using medical shorthand and abbreviations.] **MSK:**[Include concise bullet points of musculoskeletal examination findings, using medical shorthand and abbreviations.] **Derm:** [Include concise bullet points of integumentary and skin examination findings, using medical shorthand and abbreviations.] **Labs:** [include concise lab values only] **Vitals:**[Include concise bullet points of vital signs, using medical shorthand and abbreviations.]

Assessment and Plan

[List the assessment and plan using maximum shorthand and abbreviations. Ensure the section is extremely concise, without including rationales or reasonings. Use a bulleted or numeric list style consistent with the input content. Use 25 words or less.] For example: - Viral illness - Even if flu- antiviral timing is off - Counselled natural progression of viral illness - Monitor - f/u if worse In the format of the following: 1. [Problem 1] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... 2. [Problem 2] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... n. [Problem n] ([Code]): • [Management Strategy 1] • [Management Strategy 2]

Assessment and Plan

[List the assessment and plan using maximum shorthand and abbreviations. Ensure the section is extremely concise, without including rationales or reasonings. Use a bulleted or numeric list style consistent with the input content. Use 25 words or less.] For example: - Viral illness - Even if flu- antiviral timing is off - Counselled natural progression of viral illness - Monitor - f/u if worse In the format of the following: 1. [Problem 1] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... 2. [Problem 2] ([Code]): • [Management Strategy 1] • [Management Strategy 2] ... n. [Problem n] ([Code]): • [Management Strategy 1] • [Management Strategy 2]