FAMILY 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]