Clinical SOAP Note Template

Student Name:Identifying information: age and gender Source and reliability (if appropriate)SUBJECTIVE:Chief complaint: (reason for visit)HPI: (Use OLDCARTS to guide your narrative, (onset, location, duration, character, alleviating/aggravating, radiation, temporal pattern, symptoms associated with presentation) – include patient’s perception of cause (what may be going on)PMH: (system specific that could affect the acute problem Review for cancer, CAD, HTN, stroke, diabetesPSH: System specific that could affect the acute problemSH: (marital status, children, sexual history (include the 5P’s: Partners; Prevention of Pregnancy; Protection from STDs; Practices; Past History of STDs), employment, recreational substance use (past and present), physical activities, travels outside of country, military service)FH: System specific that could affect the acute problem Review for cancer, CAD, HTN, stroke, diabetesAccidents/Injuries: System specific that could affect the acute problemHospitalizations: System specific that could affect the acute problemAllergies and Reaction: medication and foodCurrent Medications: prescribed and over the counterLMP (if appropriate) Menstrual history (if indicated) OB/GYN history (if indicated)Immunizations:Review of systems: (Always start with Constitutional/General; should be relevant to the chief complaint and HPI – include pertinent positives and negatives).OBJECTIVE: (Always start with Constitutional/General; physical exam performed should be relevant to this complaint, HPI and ROS).ASSESSMENT:  Include your differential diagnosis (top 2-3 from most to least likely)PLAN:Health Promotion/Disease Prevention interventions as indicated Patient centered Patient education