SOAP Note Simple Template – Ashton

Chief Complaints:
[textarea cols=80 rows=1 default="one or more symptoms in patient's words, duration..."]
History of Present Illness:
[textarea cols=80 rows=5 default="PQRST - Provocative or Palliative maneuvers, symptom Quality, the Region involved, the Severity and Temporal pattern of symptom..."]
Past Medical and Surgical History:
[textarea cols=80 rows=4 default="chronic illness, important prior illness, operations, injuries, prior hospitalizations"]
Family History:
[textarea cols=80 rows=3 default="history for first-degree relatives or beyond"]
Social History:
[textarea cols=80 rows=3 default="place of birth, nationality and ethnicity, marital status, occupations, military history, gender preference, social and economic status, habits, violence and safety, prostheses and in-home assistance"]
Review of Systems:
[textarea cols=80 rows=1 default="SKIN: no rashes, bruising, nail or hair changes"]
[textarea cols=80 rows=1 default="EYES: no blurring/double vision/spots."]
[textarea cols=80 rows=1 default="THROAT: no pain/trouble swallowing."]
[textarea cols=80 rows=1 default="NECK: no painful nodes."]
[textarea cols=80 rows=1 default="ENDOCRINE: no tremor/palpitations/heat or cold intolerance/unusual fatigue; no polyuria/polydipsia/polyphagia"]
[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain."]
[textarea cols=80 rows=1 default="CARDIOVASCULAR: no CP/heaviness/jaw or arm pain/palpitations/leg pain with exercise/edema."]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena."]
[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]
[textarea cols=80 rows=1 default="MUSCULOSKELETAL: no pain/swelling in muscles or joints."]
[textarea cols=80 rows=1 default="NEUROLOGICAL: no weakness, headache, or other pain."]
[textarea cols=80 rows=1 default="PSYCHIATRIC: no depression/anxiety/hallucinations"]
Medications:
[textarea cols=80 rows=5 default="medication name/dose/indication/duration"]
Allergies and Medication Intolerances:
[textarea cols=80 rows=1 default="medication or substance and reaction"]
Preventive Care Services:
[textarea cols=80 rows=1 default="dates and results of screening tests and exams"]
Advance Directives:
[textarea cols=80 rows=1 default="living will and/or durable power of attorney for health care/identify surrogate decision maker"]
Physical Examination
[textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"]
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=1 default="HEAD: normocephalic."]
[textarea cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]
[textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]
[textarea cols=80 rows=1 default="NOSE: No nasal discharge."]
[textarea cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=2 default="LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=2 default="BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[textarea cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea cols=80 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."]
Laboratory and Radiology:
[textarea cols=80 rows=1 default="test, date, result"]
Assessment and Plan
[textarea cols=80 rows=2 default="#1 Problem"]
[textarea cols=80 rows=2 default="#2 Problem"]
[textarea cols=80 rows=2 default="#3 Problem"]
[textarea cols=80 rows=2 default="#4+ Problem"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
LeBlond R, Brown D, DeGowin R. DeGowin's Diagnostic Examination, 9e. New York. McGraw Hill; 2009
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