General Soap Note

Name:[text name="variable_1" default=""]
MRN:[text name="variable_2" default=""]
Admission Date:[date name="variable_3" default="03-30-2023"]
DOB/Age:[date name="variable_4" default="03-30-2023"]/[text name="variable_5" default=""] y.o.
Gender:[select name="variable_6" value="Male|Female|Other"]
Room #:
Cheif Complaint:[textarea name="variable_7" default=""]
History of Presenting Illness: A [text name="variable_8" default=""] y.o. [select name="variable_9" value="Male|Female|Other"] with a past medical history of [textarea name="variable_10" default=""] presents due to [textarea name="variable_11" default=""]
Past Surgical History: [textarea name="variable_12" default=""]
Allergies: [textarea name="variable_13" default=""]
Family History:[textarea name="variable_14" default=""]
Medications:[textarea name="variable_15" default=""]
Social History:
    Lives With:[textarea name="variable_16" default=""]
    Occupation:[textarea name="variable_17" default=""]
    Relationship:[textarea name="variable_18" default=""]
    Recent Travel:[textarea name="variable_19" default=""]
    Pets:[textarea name="variable_20" default=""]
    Tobacco: [select name="variable_21" value="Yes|No"] [text name="variable_22" default=""] years
    Alcohol: [select name="variable_23" value="Yes|No"] [text name="variable_24" default="Type"] [text name="variable_25" default=""] years
    Drugs: [select name="variable_26" value="Yes|No|"] [text name="variable_27" default="Type"] [text name="variable_28" default=""] years
    Exercise: [select name="variable_29" value="Yes|No|"] [text name="variable_30" default="Type"] [text name="variable_31" default=""] days per week.
Review of Systems:
    General: [checkbox name="variable_32" value="Weight Loss|Pain|Fever|Chills|Fatigue"]
    HEENT: [checkbox name="variable_33" value="Headache|Hearing Change|Vision Change|Vertigo|Congestion|Runny Nose|Sore Throat"]
    Respiratory: [checkbox name="variable_34" value="Cough|Hemoptysis|Dyspnea|Wheezing|Pleuritic Pain"]
    Cardiovascular: [checkbox name="variable_35" value="Palpitations|Diaphoresis|Orthopnea|Edema|Claudication|Chest Pain"]
    Gastrointestinal: [checkbox name="variable_36" value="Vomiting|Diarrhea|Constipation|Appetite Change|Bleeding"]
    Genitourinary: [checkbox name="variable_37" value="Pain with Intercourse|Discharge|Itching|Irritation|Irregular Menses|Dysmenorrhea|Hernia|Testicular Issue"]
    Urinary: [checkbox name="variable_38" value="Frequency|Urgency|Pain|Burning|Hematuria"]
    Musculoskeletal: [checkbox name="variable_39" value="Myalgia|Arthralgia|Back Pain|Swelling of Joints"]
    Skin: [checkbox name="variable_40" value="Rashes|Changes to Moles|Itching|Dryness|Color Change"]
    Endocrine: [checkbox name="variable_41" value="Hot Intolerance|Cold Intolerance|Sweating|Polydipsia|Polyuria"]
    Neurologic: [checkbox name="variable_42" value="Dizziness|Fainting|Seizures|Numbness|Tingling|Tremor"]
    Psychiatric: [checkbox name="variable_43" value="Depression|Anxiety|Memory Loss"]
Physical Exam:
    BP: [text name="variable_44" default=""] mmHg; HR: [text name="variable_45" default=""] beats/min; RR: [text name="variable_46" default=""] breaths/min; Temp: [text name="variable_47" default=""]C; SaO2: [text name="variable_48" default=""]% [text name="variable_49" default="O2 Requirement"]
    General: [checkbox name="variable_50" value="No Apparent Distress|Well Appearing|Alert|Interactive"] [text name="variable_51" default=""]
    HEENT: [checkbox name="variable_52" value="Normocephalic/Atraumatic|PERRl|EOMI|Good Conjugate Gaze|Nares Patent|MMM"] [text name="variable_53" default=""]
    Neck: [checkbox name="variable_54" value="Supple|No LAD|Normal ROM"] [text name="variable_55" default=""]
    Respiratory: [checkbox name="variable_56" value="Normal Respiratory Effort|No Wheezing|No Ronchi|No Rales|CTAB"] [text name="variable_57" default=""]
    Cardiovascular: [checkbox name="variable_58" value="RRR|S1/S2 Heart Sounds|No m/r/g"] [text name="variable_59" default=""]
    Abdominal: [checkbox name="variable_60" value="Soft|Non-distended|Non-tender|Normal Bowel Sounds|No palpable Masses"] [text name="variable_61" default=""]
    Extremities: [checkbox name="variable_62" value="Normal Tone|Normal ROM|Strength Intact|Sensation Intact|Capillary Refill <2sec"] [text name="variable_63" default=""]
    Neurological: [checkbox name="variable_64" value="A&OX3|Cranial Nerves 2-12 Intact|Reflex Symmetric|Sensation Normal|Gait Normal"] [text name="variable_66" default=""]
    Skin: [checkbox name="variable_67" value="Intact|No Rashes|No Lesions|No Erythema"] [text name="variable_68" default=""]
Labs:
    Hgb: [text name="variable_69" default=""]
    Hct: [text name="variable_70" default=""]
    WBC: [text name="variable_71" default=""]
    Plt: [text name="variable_72" default=""]
    PT: [text name="variable_73" default=""]
    PTT: [text name="variable_74" default=""]
    INR: [text name="variable_75" default=""]
    Na: [text name="variable_76" default=""]
    K: [text name="variable_77" default=""]
    Cl: [text name="variable_78" default=""]
    HCO3: [text name="variable_79" default=""]
    BUN: [text name="variable_80" default=""]
    Cr: [text name="variable_81" default=""]
    Glucose: [text name="variable_82" default=""]
    Ca: [text name="variable_83" default=""]
    Mg: [text name="variable_84" default=""]
    PO4: [text name="variable_85" default=""]
    Bili: [text name="variable_86" default=""]
    AST: [text name="variable_87" default=""]
    ALT: [text name="variable_88" default=""]
    ALKP: [text name="variable_89" default=""]
    Other Labs:[textarea name="variable_90" default=""]
    Imaging: [textarea name="variable_91" default=""]
Assessment/Plan: [textarea name="variable_92" default=""]
    
Name:
MRN:
Admission Date:
DOB/Age:/ y.o.
Gender:
Room #:
Cheif Complaint:

History of Presenting Illness: A y.o. with a past medical history of
presents due to

Past Surgical History:

Allergies:

Family History:

Medications:

Social History:
Lives With:

Occupation:

Relationship:

Recent Travel:

Pets:

Tobacco: years
Alcohol: years
Drugs: years
Exercise: days per week.
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Urinary:
Musculoskeletal:
Skin:
Endocrine:
Neurologic:
Psychiatric:
Physical Exam:
BP: mmHg; HR: beats/min; RR: breaths/min; Temp: C; SaO2: %
General:
HEENT:
Neck:
Respiratory:
Cardiovascular:
Abdominal:
Extremities:
Neurological:
Skin:
Labs:
Hgb:
Hct:
WBC:
Plt:
PT:
PTT:
INR:
Na:
K:
Cl:
HCO3:
BUN:
Cr:
Glucose:
Ca:
Mg:
PO4:
Bili:
AST:
ALT:
ALKP:
Other Labs:

Imaging:

Assessment/Plan:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.32, 91 form elements, 118 boilerplate words, 47 text boxes, 15 text areas, 2 dates, 21 checkboxes, 6 drop downs, 174 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: