Inpatient Palliative SOAP note

History of present illness

[Describe the patient's reason for admission to the hospital as an initial identifying statement. Then describe today's current symptoms, including onset, duration, severity, and any associated factors. Include relevant medical, surgical, social, and medication history as it pertains to the presenting complaint.]

Physical exam

[Document pertinent physical examination findings. If not performed, state reason (e.g., 'Deferred as today's consult was done via telehealth.')]

Vitals

[List vital signs with values and units (e.g., BP, HR, RR, Temp, SpO2). If not obtained, state reason.]

Labs

[Summarize relevant laboratory results, including dates and specific values.]

Imaging

[Summarize relevant imaging findings, including modality, date, and key results.]

Assessment and plan

[Provide a concise summary of the patient's primary diagnosis or clinical impression. Outline the management plan, including further workup, treatment, and patient instructions. Do not use the word 'follow up'; instead, use 'assessment' or specify next steps.]