Detailed SOAP Note (A & P separate)

Chief Complaint

General Medical Note Template

HPI

[Provide a detailed history of present illness including onset, duration, characteristics, associated symptoms, relieving factors and aggravating factors, and any relevant context or changes since last visit.]

Current Meds

[List all current medications the patient is taking, including dosage and frequency. List each med on a different line with a - to start the new line. For example: - [Drug] - [dosage and frequency]]

Allergies

[Document any known allergies Put drug allergies first, then environmental, then food and their relevant reaction. List in each one on a new line with - at the start. For example: - [drug] ([reaction])

Surgeries

[List all past surgeries with approximate dates. For example: - [Surgery name] ([Date or Year])]

Family Hx

[Provide relevant family medical history including health status or cause of death for immediate family members such as mother, father, siblings. For example: - Mother ([deceased or living]) - [Relevant conditions] - Father - [Relevant conditions] - Brother - [Relevant conditions]

Social

[Describe patient's social history including hobbies, exercise and eating habits, tobacco use, alcohol use, illicit drug use, living situation, and relationship status.]

Past Medical History

Lab Results

[List relevant laboratory results with dates and values. Include any pending results if applicable]

Diagnosis

[List diagnoses with corresponding ICD-10 codes. For example: - ICD 10 code: Diagnosis - ICD 10 code: Diagnosis - ICD 10 code: Diagnosis]

Treatment Plan

[Outline the treatment plan discussed during the visit. Include the following for each problem: 1. Problem - For acute problems, include differential diagnosis and pertinent vital signs. - Medications prescribed. - Education about medication adverse effects. - Patient education and counseling. - Instructions for return to clinic or emergency care for red flag symptoms (e.g., shortness of breath, chest pain, worsening symptoms, fever). 2. Problem - Relevant symptoms or chronic problems being managed. - Trends of relevant labs. - Medications used or medication changes/added. - Education about medications adverse effects - Any relevant patient counseling 3. Problem - Relevant symptoms or chronic problems being managed. - Trends of relevant labs. - Medications used or medication changes/added. - Education about medications adverse effects - Any relevant patient counseling [Continue adding problems with the template above if there are more] [only include preventative if discussed] Preventative: - Colonoscopy: [Status or date] - Immunizations: [List or UTD] - Dental: [Status or date] - Vision: [Status or date] - PSA: (men only) [Status or date] - PAP/Mammogram: (female only) [Status or date] - [if annual labs are discussed please state which annual labs ordered: CBC, CMP, TSH w/reflex, lipid panel, A1c) Follow-up in [number] (months or week) for chronic condition management. Patient instructed to return to clinic as needed for new or worsening symptoms. [Document total time spent on encounter in minutes, including review of history/records, exam, counseling, care coordination, and documentation.]

Preventative

[Document status of preventative health measures. Include dates or note if up to date (UTD). For example: - Colonoscopy: [Date or UTD] - (For females only) Pap: [Date or UTD] - (For females only) Mammogram: [Date or UTD] - (For males only) PSA: [Date or UTD] - Immunizations: [List or UTD] - Eye Exam: [Date or UTD] - Dental: [Date or UTD]

Orders

[List any orders for labs, imaging, or diagnostic tests placed during the encounter.]

New Medications

[List any new medications prescribed during this visit.]

Stopped Medications

[List any medications discontinued during this visit.]