SOAP template - VA

Subjective

[For each health issue discussed, provide extremely concise information (list form) including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. Do not use full sentences. Use format as in the example below] (Have each concern as a numbered list format) Example: 1. [Problem 1]: - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant information that was discussed] [line break] 2. [Problem 2]: - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant information that was discussed]

Subjective

[For each health issue discussed, provide extremely concise information (list form) including current symptoms, history, relevant past medical history, medication use, and any recent changes or concerns. Do not use full sentences. Use format as in the example below] (Have each concern as a numbered list format) Example: 1. [Problem 1]: - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant information that was discussed] [line break] 2. [Problem 2]: - [Symptoms and onset] - [Relevant past medical history] - [Any other relevant information that was discussed]

Objective

[Document physical examination findings, vital signs, do not comment on physical exam that was not done. ] For example: "O/" - Always start with "Well NAD" - Vital signs: BP [value], HR [value], etc. - If cardiac exam normal write it as: "CV: S1/S2, regular" - If resp exam normal write it as: "Resp: AE=AE, no adventitious sounds" - If head and neck exam normal, write it as "TM WNL, Tonsils without hypertrophy/exudates/erythema" [If it's a telehealth visit, only write "O/ Well NAD, Phone call" for the objective section.]

Objective

[Document physical examination findings, vital signs, do not comment on physical exam that was not done. ] For example: "O/" - Always start with "Well NAD" - Vital signs: BP [value], HR [value], etc. - If cardiac exam normal write it as: "CV: S1/S2, regular" - If resp exam normal write it as: "Resp: AE=AE, no adventitious sounds" - If head and neck exam normal, write it as "TM WNL, Tonsils without hypertrophy/exudates/erythema" [If it's a telehealth visit, only write "O/ Well NAD, Phone call" for the objective section.]

Assessment & Plan

[List each medical diagnosis or problem with a corresponding assessment and extremely concise 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. Always end with RTC prn. Use format as in the example below.] For example: "A/P" 1. [Diagnosis 1]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] [line break] 2. [Diagnosis 2]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] ... [line break] [n. Diagnosis n]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other]