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    SOAP Template - 2024

    Uploaded by

    Mengqi Li

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    SOAP Template - 2024

    Uploaded by

    Mengqi Li
    89 views2 pages

    Original Title

    SOAP Template- 2024

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    89 views2 pages

    SOAP Template - 2024

    Uploaded by

    Mengqi Li

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 2

    Header: BE SURE YOUR NAME IS INCLUDED!

    SOAP Template

    Identifying information: (PATIENT’s age, gender – No NAMES)

    SUBJECTIVE:

    Chief complaint
    History of Present Illness (HPI) – OLDCARTS or OLDCLASS

    Past Medical History (PMHx)

    Medications

    Allergies (Drug/Food/Environmental AND must include specific reaction types)

    Immunizations (age-appropriate)

    Family Medical History (FMHx):

    Birth History, if applicable.

    Social History (SHx)

    Review of Systems (ROS):

    General:
    HEENT:
    Cardiovascular:
    Respiratory:
    Abdomen:
    GU:
    Neuro:
    Musculoskeletal:
    Derm:
    Psych:

    OBJECTIVE (Physical Examination):

    Include appropriate systems. Regardless of order of exam, report head to toe. If


    problem focused SOAP note include: only relevant systems and should match the
    ROS systems since they were relevant there.

    Vital Signs:
    General:
    HEENT:
    Cardiovascular:
    Respiratory:
    Abdomen:
    Header: BE SURE YOUR NAME IS INCLUDED!

    GU:
    Neuro:
    Musculoskeletal:
    Derm:
    Psych:

    Laboratory Orders/Diagnostic Tests

    ASSESSMENT:

    Assessment Statement
    Differential Diagnoses (Prioritized with ICD-10 Codes)

    PLAN:
    Pharmacological
    Non-pharmacological
    Patient education
    Referral/consultations, if applicable
    Follow-up

    SDOH Reflection. Include one SDOH for each SOAP note and discuss how it was
    addressed.

    Practicum Performance Progress Note


    1. What went well with this encounter?
    2. What would you do differently if you could redo this encounter?
    5. Describe your overall progress. What are your strengths? What are
    opportunities for growth?

    Reference(s): At least one reference should be used for every SOAP note and be
    written APA format at the end of your write-up. APA in-text citations are also
    expected in the assessment and plan sections.

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