Podiatry Detailed SOAP Note Template

History

Document relevant information gathered from the patient (or alternate source) to inform care. • Identifying information – age/DOB, gender, contact, health insurance (e.g., MSP) • Reason for assessment – referral source, chief complaint(s) • Presenting condition – onset, duration, location, symptom description, aggravating/relieving factors • Pertinent positives/negatives – key historical findings related to chief complaint • Past medical history – comorbidities, previous podiatric issues/surgeries • Allergies – medication/food/environment and reactions • Medication history – current and past medications, recent changes • Social history (if relevant) – smoking, occupation, lifestyle factors

Foot/ankle vascular

[Document findings for pulses, capillary refill, and temperature of the foot and ankle.]

Neurological

[Describe sensation (e.g., monofilament testing), and reflexes.]

Dermatological

[Note skin and nail findings, including any lesions.]

Musculoskeletal/biomechanical

[Document joint motion, gait analysis, and weightbearing examination findings.]

Footwear/orthotics evaluation

[Evaluate footwear and orthotics for fit, function, and effects on gait.]

Pertinent negatives (examination)

[Document pertinent negative findings from the physical and functional exam where relevant.]

Investigation

[List diagnostic procedures ordered (e.g., imaging, doppler studies, labs) with rationale. Include findings/results (normal and abnormal) with interpretation. Document follow-up of results and how they influenced management. Note tracking of ordered tests and results in the chart.]

Investigation

[List diagnostic procedures ordered (e.g., imaging, doppler studies, labs) with rationale. Include findings/results (normal and abnormal) with interpretation. Document follow-up of results and how they influenced management. Note tracking of ordered tests and results in the chart.]

Diagnosis

[State the primary diagnosis based on history, exam, and investigation. Include differential diagnoses if definitive diagnosis is pending. Specify severity or qualification (e.g., improved, stable, worsening) if applicable.]

Diagnosis

[State the primary diagnosis based on history, exam, and investigation. Include differential diagnoses if definitive diagnosis is pending. Specify severity or qualification (e.g., improved, stable, worsening) if applicable.]

Management plan

[Outline treatment interventions and rationale. Document patient education regarding diagnosis, expectations, and risks/benefits. If procedures were performed (e.g., debridement, injections), include details, consent, and safety measures. List referrals to specialists or allied providers with expected follow-through. Specify follow-up schedule with dates or timelines for return or reassessment.]

Medication

[List medications prescribed, including name, dose, route, quantity, and repeats. Provide rationale linked to diagnosis/plan. Document discussion of side effects and precautions. Outline monitoring plan for efficacy and side effects. Update medication list to reflect changes made during the visit.]

Follow Up

[Describe progress evaluation and response to treatments over time. State next steps, including investigations to repeat or additional exams planned. Specify timelines and roles for follow-up, including who is responsible and deadlines. Document coordination and communication with other providers involved in care.]