SOAP
Patient Initials: |
Pt. Encounter Number: |
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Date: |
Age: |
Sex: |
Allergies: Advanced Directives: |
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SUBJECTIVE |
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CC: |
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HPI:
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Current Medications: |
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PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: |
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Family History: |
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Social History: |
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ROS |
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General |
Cardiovascular |
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Skin |
Respiratory |
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Eyes |
Gastrointestinal |
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Ears |
Genitourinary/Gynecological |
SOAP NOTE
Nose/Mouth/Throat |
Musculoskeletal |
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Breast |
Neurological |
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Heme/Lymph/Endo |
Psychiatric |
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OBJECTIVE |
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Weight BMI |
Temp |
BP |
Height |
Pulse |
Resp |
PHYSICAL EXAMINATION |
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General Appearance |
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Skin |
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HEENT |
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Cardiovascular |
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Respiratory |
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Gastrointestinal |
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Breast |
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Genitourinary |
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Musculoskeletal |
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Neurological |
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Psychiatric |
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Lab Tests |
Special Tests |
Diagnosis |
· Primary Diagnosis- Evidence for primary diagnosis should be Objective exams. o Differential Diagnoses PLAN including education o Plan: Further testing Medication Education Non-medication treatments · Referrals Follow-up visits |
References |