SOAP Note

This document follows the SOAP note format (Subjective, Objective, Assessment, Plan), a widely used method for documenting clinical encounters between healthcare providers and patients. It helps in maintaining structured, accurate, and effective medical records.

Patient Information

• Name: {name}
• Date of Birth: {dob}
• Gender: {gender}
• Date of Visit: {dateOfVisit}
• Provider: {providerName}

Subjective

Chief Complaint: {chiefComplaint}

History of Present Illness: {hpi}

Past Medical History: {pastMedicalHistory}

Medications: {medications}

Allergies: {allergies}

Social History: {socialHistory}

Review of Systems: {reviewOfSystems}

Objective

Vital Signs:

• Blood Pressure: {bloodPressure}
• Heart Rate: {heartRate}
• Respiratory Rate: {respiratoryRate}
• Temperature: {temperature}
• Oxygen Saturation: {oxygenSaturation}
• Height: {height}
• Weight: {weight}

Physical Exam Findings:

{physicalExam}

Diagnostic Test Results:

{diagnosticResults}

Assessment

Primary Diagnosis: {primaryDiagnosis}

Differential Diagnoses:

{differentialDiagnoses}

Plan

Treatment Plan:

{treatmentPlan}

Medications Prescribed:

{#medicationsPrescribed}

• {medName} — {dosage}, {frequency}, {duration}

{/medicationsPrescribed}

Recommendations/Instructions:

{recommendations}

Follow-Up:

• Next Appointment: {nextAppointment}
• Provider to Follow-Up: {followUpProvider}

Additional Notes: {additionalNotes}