SOAP NOTE

Patient: [Name]
Date of birth: [Date]
Date of visit: [Date]
Visit type: [In person or telehealth; new or follow-up]
Clinician: [Name, credentials]

SUBJECTIVE
Chief complaint: [Reason for the visit, in the patient's words]
History of present illness: [Onset, location, duration, character, what makes it better or worse, timing, severity]
Relevant history: [Past medical, surgical, family, and social history that bears on today's problem]
Medications: [Current medications, doses, adherence]
Allergies: [Drug and other allergies, with reactions]
Review of systems: [Pertinent positives and negatives]

OBJECTIVE
Vital signs: [BP, HR, RR, temperature, SpO2, weight]
Examination: [Findings by system, focused on the complaint]
Results: [Labs, imaging, and other tests reviewed, with dates]

ASSESSMENT
Problem 1: [Diagnosis or working impression, with the findings that support it]
Differential: [Other diagnoses considered, and why they are more or less likely]
Status: [New, improving, stable, or worsening]

PLAN
Investigations: [Tests ordered]
Treatment: [Medications with dose, route, and frequency; procedures; referrals]
Education: [What was discussed, and the patient's understanding and agreement]
Follow-up: [When, with whom, and when to return sooner]

Signed: [Clinician name, credentials, date and time]