Outpatient Examination Form v2

# Outpatient Examination Form

Patient ID: ________________   Date: ________________

## Vitals
- BP: ____/____ mmHg
- Pulse: ____ bpm
- Temp: ____ °F
- Resp Rate: ____ /min
- O2 Sat: ____% on: [ ] Room air  [ ] __ L O2

## Chief Complaint
______________________________________________

## History of Present Illness
______________________________________________
______________________________________________
______________________________________________

## Review of Systems
[ ] Constitutional  [ ] HEENT  [ ] Cardiovascular  [ ] Respiratory
[ ] Gastrointestinal  [ ] Genitourinary  [ ] Musculoskeletal
[ ] Neurological  [ ] Psychiatric  [ ] Endocrine  [ ] Hematologic
[ ] Allergic/Immunologic

Notes: _________________________________________

## Physical Examination

```
                 Anterior                 Posterior
                   ____                     ____
                  /    \                   /    \
     Right  -->  | O  O |  <-- Left       |      |
                 |   ^  |                 |      |
                 \  ~  /                  |      |
                  |   |                   |      |
               ___|___|___             ___|______|___
              /   \   /   \           /   \      /   \
             |     | |     |         |     |    |     |
            /   O   O   O   \       /   O        O    \
           |    |   |   |    |     |    |        |     |
           |     \ | /      |      |     \      /      |
            \     \|/      /        \     \    /      /
             \     |      /          \     \  /      /
              \    |     /            \     \/      /
               \   |    /              \    ||     /
                \  |   /                \   ||    /
                 \ | /                   \  ||   /
                  \|/                     \ || /
                   |                       \||/
                  / \                       \/
                 /   \                     /  \
                /     \                   /    \
               /       \                 /      \
              /         \               /        \
         ____/           \____     ____/          \____
        /                     \   /                    \
       |                       | |                      |
        \_____________________ /   \____________________ /
```

## Problem-Based Assessment and Plan

1. Problem: _______________________________
   - Assessment: __________________________
   - Plan:
     a) ___________________________________
     b) ___________________________________
     c) ___________________________________

2. Problem: _______________________________
   - Assessment: __________________________
   - Plan:
     a) ___________________________________
     b) ___________________________________
     c) ___________________________________

3. Problem: _______________________________
   - Assessment: __________________________
   - Plan:
     a) ___________________________________
     b) ___________________________________
     c) ___________________________________

## Medications
[ ] No changes
[ ] Changes (specify): _________________________

## Follow-up
[ ] 1 week  [ ] 2 weeks  [ ] 1 month  [ ] 3 months  [ ] As needed

Additional Notes:
______________________________________________
______________________________________________

Provider Signature: ___________________________
# Outpatient Examination Form

Patient ID: ________________ Date: ________________

## Vitals
- BP: ____/____ mmHg
- Pulse: ____ bpm
- Temp: ____ °F
- Resp Rate: ____ /min
- O2 Sat: ____% on: [ ] Room air [ ] __ L O2

## Chief Complaint
______________________________________________

## History of Present Illness
______________________________________________
______________________________________________
______________________________________________

## Review of Systems
[ ] Constitutional [ ] HEENT [ ] Cardiovascular [ ] Respiratory
[ ] Gastrointestinal [ ] Genitourinary [ ] Musculoskeletal
[ ] Neurological [ ] Psychiatric [ ] Endocrine [ ] Hematologic
[ ] Allergic/Immunologic

Notes: _________________________________________

## Physical Examination

```
Anterior Posterior
____ ____
/ \ / \
Right --> | O O | <-- Left | |
| ^ | | |
\ ~ / | |
| | | |
___|___|___ ___|______|___
/ \ / \ / \ / \
| | | | | | | |
/ O O O \ / O O \
| | | | | | | | |
| \ | / | | \ / |
\ \|/ / \ \ / /
\ | / \ \ / /
\ | / \ \/ /
\ | / \ || /
\ | / \ || /
\ | / \ || /
\|/ \ || /
| \||/
/ \ \/
/ \ / \
/ \ / \
/ \ / \
/ \ / \
____/ \____ ____/ \____
/ \ / \
| | | |
\_____________________ / \____________________ /
```

## Problem-Based Assessment and Plan

1. Problem: _______________________________
- Assessment: __________________________
- Plan:
a) ___________________________________
b) ___________________________________
c) ___________________________________

2. Problem: _______________________________
- Assessment: __________________________
- Plan:
a) ___________________________________
b) ___________________________________
c) ___________________________________

3. Problem: _______________________________
- Assessment: __________________________
- Plan:
a) ___________________________________
b) ___________________________________
c) ___________________________________

## Medications
[ ] No changes
[ ] Changes (specify): _________________________

## Follow-up
[ ] 1 week [ ] 2 weeks [ ] 1 month [ ] 3 months [ ] As needed

Additional Notes:
______________________________________________
______________________________________________

Provider Signature: ___________________________

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 112 boilerplate words
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: