SOAP note

[textarea name="variable_preamble"]Preamble
Reason for contact
Contact type - phone, home visit, clinic[/textarea]

[textarea name="variable_subjective"]Subjective/History
what the patient/caregivers said.
Onset
Location
Duration
Character (sharp, dull, etc.)
Alleviating/Aggravating factors
Radiation
Temporal pattern (every morning, all day, etc.)
Symptoms associated
[/textarea]
[link memo="History Templates" url="https://www.soapnote.org/category/subjective/"] [comment memo_color="red" memo="&"] [link memo="Review Of Systems (ROS)" url="https://www.soapnote.org/tag/review-of-systems/"] [comment memo_color="red" memo="&"] [link memo="Popular ROS template" url="https://www.soapnote.org/general/physical-exam-review-of-systems-templates/"]

[textarea name="variable_objective"]Objective/Observation/Examination
what was assessed, measured, observed, witnessed
[/textarea]
[link url="https://www.soapnote.org/objective/general-adult-physical-exams/" memo="Popular template"] [comment memo_color="red" memo="&"] [link memo="More templates" url="https://www.soapnote.org/category/objective/"] [comment memo_color="red" memo="&"] [link url="https://www.soapnote.org/general/lab-fishbone/" memo="Lab fishbone"]

[textarea name="variable_assessment"]Assessment/Impression
Diagnoses
Differential considerations[/textarea]

[textarea name="variable_plan"]Plan/Treatment
What happens next?
Reasons for any changes to care plan.
How to monitor?
Who is going to do what, how often, starting
when? 
Date/timeframe for next expected contact.
Referring elsewhere? Who to, what for, and when
was it done?
If it is a final contact, reasons for discharge.
Details of advice given or education material issued.[/textarea]
[link memo="Templates" url="https://www.soapnote.org/category/plan/"] [comment memo_color="red" memo="&"] [link memo="Differential diagnosis" url="https://www.soapnote.org/tag/differential-diagnosis/"] [comment memo_color="red" memo="&"] [link memo="Imaging" url="https://www.soapnote.org/general/mri-ct-tool/"] [comment memo_color="red" memo="&"] [link url="https://www.soapnote.org/category/patient-education/" memo="Patient education"]
[checkbox memo="display/hide notes & references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
notes & references:
[link memo="#1" url="https://www.ncbi.nlm.nih.gov/books/NBK482263/"] Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2022 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.[/conditional]



History Templates & Review Of Systems (ROS) & Popular ROS template


Popular template & More templates & Lab fishbone




Templates & Differential diagnosis & Imaging & Patient education
display/hide notes & references

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Sandbox Metrics: Structured Data Index 0.17, 25 form elements, 5 text areas, 1 checkboxes, 11 links, 7 comments, 1 conditionals, 6 total clicks
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