Podiatry SOAP template - detailed examination

History of present illness

[Document in detail the patient's history of present illness, including the nature, location, duration, onset, and any past treatments related to the current complaint. Write it in a list form with dashes] For example - 1. Right fifth toe corn: - He reports persistent corn at the right fifth toe, previously shaved a couple of weeks ago with some relief. - He describes ongoing discomfort due to bony prominence and rubbing between the fourth and fifth toes. - No dramatic findings or deformities noted by self-report. - No new or unusual symptoms reported.

Social history

[Document the patient's social history, including details about work, exercise habits, smoking status, and drug use. Only include information as discussed in the encounter transcript]

Family history

[Include any relevant family medical history that may contribute to the patient's condition.]

Surgical history

[List any past surgical procedures that are relevant to the patient's current podiatric condition or chief complaint]

Vascular exam

[Document findings from the vascular examination, including any abnormalities or significant observations.]

Pedal neurological exam

[Record the results of the pedal neurological examination, noting any deficits or abnormalities.]

Ortho/Biomechanical exam

[Provide details of the orthopedic or biomechanical examination, including any relevant findings.]

Dermatological exam

[Describe the findings from the dermatological examination, including any skin-related observations.]

Impression

[Provide a numbered list of diagnostic impressions, including ICD9 diagnostic codes for each identified condition.] For example - 1. [Diagnosis 1] [ICD 9] 2. [Diagnosis 2] [ICD 9]

Treatment plan

[Outline the treatment plan for as a numbered list including any medications, therapies, or follow-up recommendations.]