General SOAP Note

Subjective

[Document only what was explicitly reported by the patient during this encounter. Do not add, infer, or negate. Structure: - One numbered entry per active problem discussed - Medications nest as a bullet under their relevant problem — never as a standalone section - Omit fields entirely if not discussed — do not document absence - No allergy documentation unless a new allergy was reported this encounter - No negation bullets (e.g., "no new sx," "denies CP") - No lab values, vital signs, or test results — these belong in Objective only - No clinician interpretation or assessment language (e.g., "BP control: improved," "BG control: stable") — Subjective contains only patient-reported data Format per problem: [Problem name] - [Symptom / status / relevant history — brief, high-signal phrases only] - Medications: [drug, dose if stated, adherence, side effects if discussed] - [Any other directly relevant detail from transcript] Example (Correct): 1. Type 2 Diabetes Mellitus - Home BG monitoring ~3x/week (fasting, mornings) - Dietary improvements underway; walking increased - Medications: metformin daily, adherent, no side effects - FHx: younger brother recently diagnosed with diabetes 2. Hypertension - Limited sodium awareness prior to this visit - Medications: ramipril daily, adherent, no side effects Example (Incorrect — Do Not Follow): 1. Type 2 Diabetes Mellitus - No new symptoms reported - No known allergies 2. Hypertension - No new symptoms reported - No known allergies 3. Medications ← NEVER create this section - Metformin daily - Ramipril daily]

Subjective

[Document only what was explicitly reported by the patient during this encounter. Do not add, infer, or negate. Structure: - One numbered entry per active problem discussed - Medications nest as a bullet under their relevant problem — never as a standalone section - Omit fields entirely if not discussed — do not document absence - No allergy documentation unless a new allergy was reported this encounter - No negation bullets (e.g., "no new sx," "denies CP") - No lab values, vital signs, or test results — these belong in Objective only - No clinician interpretation or assessment language (e.g., "BP control: improved," "BG control: stable") — Subjective contains only patient-reported data Format per problem: [Problem name] - [Symptom / status / relevant history — brief, high-signal phrases only] - Medications: [drug, dose if stated, adherence, side effects if discussed] - [Any other directly relevant detail from transcript] Example (Correct): 1. Type 2 Diabetes Mellitus - Home BG monitoring ~3x/week (fasting, mornings) - Dietary improvements underway; walking increased - Medications: metformin daily, adherent, no side effects - FHx: younger brother recently diagnosed with diabetes 2. Hypertension - Limited sodium awareness prior to this visit - Medications: ramipril daily, adherent, no side effects Example (Incorrect — Do Not Follow): 1. Type 2 Diabetes Mellitus - No new symptoms reported - No known allergies 2. Hypertension - No new symptoms reported - No known allergies 3. Medications ← NEVER create this section - Metformin daily - Ramipril daily]

Objective

Document only clinician-measured or in-clinic data. No patient-reported content in this section. Rules: - Group by data type: Vitals -> Labs -> Exam - Include lab recency if stated (e.g., "today," "within 3 months") - Include clinician-stated targets inline with results (e.g., target <7%) - Exam findings: state positives; omit normal systems unless directly relevant - No interpretation or assessment language in this section - If a subsection has no in-clinic data (e.g., no labs drawn this visit), omit that subsection entirely — do not substitute history, negations, or patient-reported info to fill it - No patient-reported vitals (e.g., "BP high-normal per pt") — only clinician-measured values belong here - Pertinent negatives: include ONLY findings that rule out a dangerous or alternative diagnosis for the presenting complaint — maximum 4 items, consolidated into one line. Ask: "Does this negative change the diagnosis or rule out something serious?" If no — omit it. Never include PMHx, allergies, medications, social history, or general health status as pertinent negatives. Format: Vitals: - [Measurement]: [value] ([context if relevant, e.g., "improved vs last visit"]) Labs ([recency if stated]): - [Test]: [value] (target: [value] if stated) Exam: - [System]: [finding] - Pertinent negatives: [max 4 items that rule out dangerous alternative diagnoses only — omit line entirely if nothing qualifies] ════════════════ CORRECT EXAMPLE: ════════════════ Vitals: - BP: 138/84 mmHg (elevated; improved vs last visit; target <130/80) - Wt: 84 kg | BMI: 28.3 Labs (today/recent): - Fasting BG: 7.8 mmol/L (today) - HbA1c: 7.2% (recent; target <7%) - LDL: 2.4 mmol/L (recent; target <2.0) - TG: 1.8 mmol/L (recent; mildly elevated) Exam: - CVS: normal heart sounds - Resp: clear - Abd: soft, non-tender - Feet: sensation intact; no ulcers/skin chg - Pertinent negatives: no N/V, no vision changes related to HA, no bladder/bowel loss, no focal neuro deficit ══════════════════════════════════════ INCORRECT EXAMPLE — DO NOT FOLLOW: ══════════════════════════════════════ Labs: - No diabetes <- not a lab result - No cardiac problems <- not a lab result - No medication allergies <- wrong section Vitals: - BP high-normal per pt <- patient-reported, not measured Exam: - No focal deficit <- scattered, use - No skull abnormality pertinent - No mobility problems negatives line Pertinent negatives: <- NEVER list - no high BP PMHx or general - no diabetes health here - no cardiac problems <- NEVER list - no med allergies allergies or - no mobility problems medications here Pertinent negatives: <- CORRECT format no N/V, no vision chg max 4 items, related to HA, no red flags only bladder/bowel loss, no focal neuro deficit

Objective

Document only clinician-measured or in-clinic data. No patient-reported content in this section. Rules: - Group by data type: Vitals -> Labs -> Exam - Include lab recency if stated (e.g., "today," "within 3 months") - Include clinician-stated targets inline with results (e.g., target <7%) - Exam findings: state positives; omit normal systems unless directly relevant - No interpretation or assessment language in this section - If a subsection has no in-clinic data (e.g., no labs drawn this visit), omit that subsection entirely — do not substitute history, negations, or patient-reported info to fill it - No patient-reported vitals (e.g., "BP high-normal per pt") — only clinician-measured values belong here - Pertinent negatives: include ONLY findings that rule out a dangerous or alternative diagnosis for the presenting complaint — maximum 4 items, consolidated into one line. Ask: "Does this negative change the diagnosis or rule out something serious?" If no — omit it. Never include PMHx, allergies, medications, social history, or general health status as pertinent negatives. Format: Vitals: - [Measurement]: [value] ([context if relevant, e.g., "improved vs last visit"]) Labs ([recency if stated]): - [Test]: [value] (target: [value] if stated) Exam: - [System]: [finding] - Pertinent negatives: [max 4 items that rule out dangerous alternative diagnoses only — omit line entirely if nothing qualifies] ════════════════ CORRECT EXAMPLE: ════════════════ Vitals: - BP: 138/84 mmHg (elevated; improved vs last visit; target <130/80) - Wt: 84 kg | BMI: 28.3 Labs (today/recent): - Fasting BG: 7.8 mmol/L (today) - HbA1c: 7.2% (recent; target <7%) - LDL: 2.4 mmol/L (recent; target <2.0) - TG: 1.8 mmol/L (recent; mildly elevated) Exam: - CVS: normal heart sounds - Resp: clear - Abd: soft, non-tender - Feet: sensation intact; no ulcers/skin chg - Pertinent negatives: no N/V, no vision changes related to HA, no bladder/bowel loss, no focal neuro deficit ══════════════════════════════════════ INCORRECT EXAMPLE — DO NOT FOLLOW: ══════════════════════════════════════ Labs: - No diabetes <- not a lab result - No cardiac problems <- not a lab result - No medication allergies <- wrong section Vitals: - BP high-normal per pt <- patient-reported, not measured Exam: - No focal deficit <- scattered, use - No skull abnormality pertinent - No mobility problems negatives line Pertinent negatives: <- NEVER list - no high BP PMHx or general - no diabetes health here - no cardiac problems <- NEVER list - no med allergies allergies or - no mobility problems medications here Pertinent negatives: <- CORRECT format no N/V, no vision chg max 4 items, related to HA, no red flags only bladder/bowel loss, no focal neuro deficit

Assessment and Plan

[Rules: - List ALL diagnoses first, one per line - Include control status only if stated or clearly supported by objective findings - Do NOT add brief descriptions or clinical context after diagnosis names - Then provide ALL plan elements together in one consolidated block - Consolidate shared plan elements — do not repeat per diagnosis - If physician signals plan transition (e.g., "plan," "this is the plan"), capture that content as stated - Include risk counseling if discussed, under Plan — not per diagnosis Format: Diagnoses: 1. [Diagnosis — control status if stated] 2. [Diagnosis — control status if stated] n. [Diagnosis — control status if stated] Plan: - [Medications / treatment changes] - [Investigations / referrals] - [Counseling / patient education if discussed] - [Follow-up] ════════════════ CORRECT EXAMPLE: ════════════════ Diagnoses: 1. T2DM — suboptimal control (HbA1c 7.2%; target <7%) 2. HTN — not at target (BP 138/84; target <130/80) 3. Dyslipidemia — LDL above target (2.4 mmol/L; target <2.0) Plan: - Continue metformin + ramipril; no chg - Repeat labs in 3 months (BG, HbA1c, lipids) - Refer to dietitian - Home BG monitoring: continue ~3x/wk fasting; maintain log - Diet: high-fibre, low-GI; decr sugary drinks; Na+ <1 tsp/day incl. processed foods; use herbs/garlic/lemon instead of salt - Exercise: continue walking; add strength training 2x/wk - Counseling: uncontrolled DM + HTN — incr risk MI, stroke, renal disease; targets reviewed - F/U in 3 months]