Several problems. One clear draft.
Vero Scribe writes the note in your template from the visit conversation, with the patient’s consent, or from your dictation. You review and edit it, then copy it into your EHR. Vero works in 60+ languages.
Family Medicine SOAP Note Template
A family medicine SOAP note records a visit with several concerns: the agenda, each problem with its own assessment and plan, and the prevention done along the way. Copy the free template, see an adult and a pediatric example, and check what goes in each part.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank family medicine SOAP note template
FreeFAMILY MEDICINE SOAP NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Seen with: [Alone, or who came with the patient and their relationship] Clinician: [Name, credentials] AGENDA Concerns raised: [Every concern the patient listed at the start, in their words] Agreed for today: [The concerns chosen together, numbered in order of priority] Deferred: [Concerns moved to another visit, and when it is booked] SUBJECTIVE Problem 1: [Concern, with onset, course, key symptoms, and what has been tried] Problem 2: [Concern, with onset, course, key symptoms, and what has been tried] Problem 3: [Concern, with its history] Medications: [Current list, with changes since the last visit] Allergies: [Drug and other allergies, with reactions] Relevant history: [Past medical, family, and social history that bears on today's problems] OBJECTIVE Vital signs: [BP, HR, RR, temperature, SpO2, weight] Examination: [Focused findings, grouped by problem number] Results: [Tests reviewed today, with dates] ASSESSMENT AND PLAN Problem 1: [Impression and status, with the findings that support it] Plan: [Tests, treatment with dose and frequency, education, and follow-up] Problem 2: [Impression and status, with the findings that support it] Plan: [Tests, treatment, education, and follow-up] Problem 3: [Impression and status] Plan: [Tests, treatment, education, and follow-up] HEALTH MAINTENANCE Due: [Screening or vaccines due per current guidelines for age and risk] Done today: [Given, ordered, booked, or declined, with the reason] FOLLOW-UP Next visit: [When, with whom, and for which problems] Return sooner if: [Warning signs for each problem] Signed: [Clinician name, credentials, date and time]
Use it for
- Multi-problem visits
- Same-day visits
- Pediatric visits
- Chronic care rechecks
- Opportunistic screening
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Family medicine SOAP note: blood pressure, knee pain, and screening
Family medicine, follow-up visit
Agenda
58-year-old woman. Concerns raised: blood pressure check, right knee pain, and poor sleep with hot flashes. Agreed for today: 1. hypertension, 2. right knee pain. Deferred: sleep and hot flashes, booked for a visit in 2 weeks. Raised by the clinician: mammogram overdue.
Subjective
1. Hypertension: started hydrochlorothiazide 12.5 mg daily 4 weeks ago and takes it every morning. Home readings average 128/80 this week, down from 152/94 before treatment. No dizziness, cramps, or palpitations. 2. Right knee pain: 6 weeks, gradual, no injury. Aches on stairs and after walking more than 20 minutes; stiff for 10 minutes in the morning. No locking, giving way, swelling, redness, fever, or pain at night. Medications: hydrochlorothiazide 12.5 mg daily; acetaminophen now and then for the knee, with little effect. Allergies: none known. Relevant history: walks for exercise; her mother had both knees replaced.
Objective
BP 128/78, repeat 126/76; HR 72; weight 84 kg (185 lb), BMI 31.2. 1. Heart regular, no edema. 2. Right knee: no effusion, warmth, or redness; tender over the medial joint line; crepitus on movement; full extension, flexion to 120°; ligaments stable; McMurray test negative. Hips move fully without pain. Gait normal. Results: sodium, potassium, and creatinine normal 2 weeks after starting hydrochlorothiazide.
Assessment and plan
1. Hypertension, at target on hydrochlorothiazide, with normal electrolytes and no side effects. Plan: continue 12.5 mg daily; home readings twice a week; review in 3 months. 2. Right knee pain, most likely osteoarthritis: age, gradual onset, pain with use, brief morning stiffness, crepitus, no effusion or instability. X-ray not needed now. Plan: physical therapy referral for a strengthening program; topical diclofenac gel to the knee as directed, up to 4 times a day; oral NSAIDs avoided because of her blood pressure. She chose a walking and stationary cycling plan, working toward weight loss. X-ray if not improving in 6 to 8 weeks, or sooner for locking or swelling.
Health maintenance
Due: mammogram, last done 4 years ago. Colonoscopy 4 years ago was normal; next in 6 years. Done today: mammogram ordered; she will book it this month.
Follow-up
Visit in 2 weeks for sleep and hot flashes. Blood pressure review in 3 months. Return sooner for a hot, swollen knee, inability to bear weight, or fever; or for dizziness, fainting, or home readings back above her target.
Family medicine SOAP note: ear pain in a child
Family medicine, same-day visit with a parent
Agenda
9-year-old boy, seen with his mother. Concerns raised: right ear pain; his mother also asked about his 3-year-old sister’s rash. Agreed for today: 1. right ear pain. The sister’s rash is not assessed in this note: she was booked into her own visit after his, documented in her own chart. Raised by the clinician: influenza vaccine due.
Subjective
1. Right ear pain: 2 days, worse when he lies on that side or touches the ear. Swimming lessons 3 times a week. Hearing slightly muffled on the right. No fever, discharge, cold symptoms, or dizziness. Ibuprofen helps. Medications: ibuprofen as needed. Allergies: none known. Relevant history: no ear surgery or ear tubes; immunizations up to date apart from this season’s influenza vaccine.
Objective
T 36.9 °C (98.4 °F), HR 88, height 133 cm (52 in), weight 28 kg (62 lb). Comfortable. 1. Right ear: pain on pulling the outer ear and pressing the tragus; canal red and swollen with white debris; eardrum partly seen, intact. Left ear normal. No redness or swelling of the outer ear or behind it. No neck lymph nodes.
Assessment and plan
1. Acute otitis externa, right ear: pain on moving the outer ear, a swollen canal with debris, an intact eardrum, and regular swimming. No spread beyond the canal. Plan: ciprofloxacin-dexamethasone ear drops, 4 drops in the right ear twice daily for 7 days; his mother was shown how to give them, with him lying on his side for a few minutes after. Keep the ear dry: no swimming for 7 to 10 days, and a cotton ball with petroleum jelly in the ear for showers. Ibuprofen or acetaminophen by weight for pain. Oral antibiotics not needed.
Health maintenance
Due: this season’s influenza vaccine. Done today: given; a mild illness is not a reason to delay it. Growth: height and weight both near the 50th percentile, following his curve.
Follow-up
No routine follow-up. Return if the pain isn’t better in 2 to 3 days, or sooner for fever, redness or swelling spreading to the outer ear or behind it, or new discharge. Recheck his hearing if it hasn’t returned to normal once the infection clears.
What goes in each part.
Agenda
Every concern the patient brought, collected at the start, and what you agreed to cover today.
- All concerns, before you start on the first one
- The ones agreed for today, numbered
- Concerns deferred, and when they are booked
- Items you raised, such as overdue screening
Avoid: Starting on the first concern before asking whether there are others.
Subjective
A short history for each numbered problem, then the medications, allergies, and history they share.
- Each problem under its own number
- Onset, course, key symptoms, and what has been tried
- Pertinent negatives and red flags asked about
- Medication changes since the last visit
Avoid: One running paragraph that mixes the history of every problem together.
Objective
Vital signs, then focused findings grouped by problem, so each assessment can point to its evidence.
- Vital signs, with a repeat if abnormal
- A focused exam for each problem, labeled by number
- Results reviewed today, with dates
Avoid: A head-to-toe normal exam that buries the findings each problem depends on.
Assessment and plan
For each numbered problem, your impression and its plan, kept together.
- The impression and its status: new, improving, stable, or worse
- The findings that support it
- Tests, treatment with dose and frequency, and education
- How the plans affect each other
Avoid: Restating the symptom, like “knee pain,” instead of giving an impression with its evidence.
Health maintenance
Screening and vaccines due, dealt with when the visit allows, even though the patient came for something else.
- Items due per current guidelines for age and risk
- What was done: given, ordered, booked, or declined
- For children: growth and immunizations
Avoid: Noting that something is due without recording what you did about it.
Follow-up
When the patient comes back, for which problems, and when to come back sooner.
- The next visit, and the problems it is for
- Deferred concerns, with their booking
- Warning signs, problem by problem
Avoid: One generic return instruction for several different problems.
Common mistakes, and how to avoid them.
The concern raised at the door
The most worrying concern often comes up as the patient is leaving. Asking for every concern at the start gives you time to fit it in or book it properly.
Plans that clash across problems
Check each plan against the others. An oral NSAID for knee pain can raise blood pressure, and so can a decongestant for a cold.
Two patients in one note
When a parent asks about a sibling, that child’s care belongs in their own chart, even if you only gave advice.
Deferred concerns that disappear
Record what you deferred and when it is booked, so the concern isn’t lost between visits.
Missing the chance for prevention
A visit for something else is often the best chance to catch overdue screening or vaccines. Check what is due, and record what you did.
Try Vero free
Frequently asked questions.
How do you write a SOAP note for a visit with several problems?
Set the agenda first, then number each problem. Keep a short history and focused findings for each, give each its own assessment and plan, and record health maintenance separately.
Should agenda setting be documented?
Yes, briefly. Listing every concern raised, the ones addressed, and the ones deferred shows what the visit covered, and makes sure deferred concerns get booked.
Can I document two family members in one note?
No. Each patient needs their own note. If a parent asks about a sibling, record that child’s assessment or advice in the sibling’s own chart.
Should health maintenance go in a note for an acute visit?
Yes, when you address it. Note what was due and what you did: given, ordered, booked, or declined, so the next clinician doesn’t have to ask again.
How is this different from the standard SOAP note?
It keeps the four SOAP parts, and adds an agenda, numbered problems throughout, and sections for health maintenance and follow-up, to fit how family medicine visits run.
Is this family medicine SOAP note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More family medicine and primary care templates, and guides.
SOAP note template
The four-part note for most visits, with acute, musculoskeletal, and telehealth examples.
Annual physical exam template
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
Chronic disease follow-up note template
Problem-by-problem review of long-term conditions: control, adherence, complication screening, and plan.
Telehealth visit note template
For video and phone visits: consent, location, what you could observe, its limits, and safety-netting.
AI scribe for family medicine
Family medicine examples, with templates for well-child, adult, and older adult visits.
Assessment and plan
Combined and problem-oriented formats for multi-problem notes.
How to write a SOAP note
A step-by-step guide, with a checklist and the most common mistakes.
Vero for family medicine and primary care
Notes, documents, and follow-up in one workspace.
Common ICD-10 codes
The codes used most often in family medicine and primary care.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
Try Vero free
No credit card required. 10 free actions every month.