SOAP Template (A&P By Problem) - Abbreviation

Subjective

[For each health issue, provide detailed bullet points including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. (Use bullet point for clarify)] (Have each concern as a numbered list format) Example: For example: 1. Cough - Duration 3 days - Non-productive - No hemoptysis 2. Headache - Duration 1 week - Intermittent - No visual changes

Subjective

[For each health issue, provide detailed bullet points including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. (Use bullet point for clarify)] (Have each concern as a numbered list format) Example: For example: 1. Cough - Duration 3 days - Non-productive - No hemoptysis 2. Headache - Duration 1 week - Intermittent - No visual changes

Objective

[Document physical examination findings, vital signs, and results of any recent diagnostic tests or imaging studies relevant to the patient's current complaints. Include specific details such as dates of imaging, measurements, and clinical observations. (Write it in bullet point)] For example: • [Imaging study and date] shows [findings]. • Vital signs: BP [value], HR [value], etc. • Physical exam findings: [describe relevant systems and observations]. [If it's a televisit or audio visit, write "No examination is performed due to Televisit" for the Physical Exam Findings.]

Objective

[Document physical examination findings, vital signs, and results of any recent diagnostic tests or imaging studies relevant to the patient's current complaints. Include specific details such as dates of imaging, measurements, and clinical observations. (Write it in bullet point)] For example: • [Imaging study and date] shows [findings]. • Vital signs: BP [value], HR [value], etc. • Physical exam findings: [describe relevant systems and observations]. [If it's a televisit or audio visit, write "No examination is performed due to Televisit" for the Physical Exam Findings.]

Assessment & Plan

[List each medical diagnosis or problem with a corresponding assessment and detailed management plan. Include differential diagnoses if applicable. Specify medications, dosages, follow-up plans, referrals, and any additional investigations required. Separate each problem and plan clearly.] For example: 1. [Diagnosis 1]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] 2. [Diagnosis 2]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] ... [n. Diagnosis n]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other]