Adult Soap Note
DOS:[date name="DOS" default=""] Name:[text name="Name" default=""] Date of Birth:[text name="Date_of_Birth": default=""] Gender:[text name="Gender": default=""] [select name="" value="SOAP Note|Progress Note"] Medication Reconcilitation: Current Medications [textarea name="CurrentMedications" default=""] Subjective CC: Follow up of chronic health conditions listed below including [textarea name="additionalconditions" default=""] [text name="Problem_1" default=""] [textarea name="Problem_1Note" default=""] [text name="Problem_2" default=""] [textarea name="problem_2note" default=""] [text name="problem_3" default=""] [textarea name="Problem_3note" default=""] [text name="Problem_4" default=""] [textarea name="Problem_4note" default=""] [text name="problem_5" default=""] [textarea name="problem_5notes" default=""] [text name="problem_6" default=""] [textarea name="problem_6notes" default=""] REVIEW OF SYSTEMS: General: [checklist name="General" value="fever|chills|fatigue|appetite changes|weight change"] Head:[checklist name="Head" value="headaches|drooling|head injury"] Eyes:[checklist name="Eyes" value="vision changes|eye pain|double vision|blurred vision|flashing lights|floaters|corrective lenses"] Ears:[checklist name="Ears" value="change in hearing|ear pain|discharge|ringing|dizziness"] Nose/Sinus:[checklist name="NoseSinus" value="nose bleeds|congestion|discharge|frequent colds,sinus infections"] Cardio:[checklist name="Cardio" value="chest pain|palpitations|heart murmur|history of heart medications|rheumatic heart disease|high blood pressure|high cholesterol|change in color of fingers or toes|swelling in hands or feet"] Pulmonology:[checklist name="Pulm" value="shortness of breath|cough|production of phlegm|coughing up blood|bronchitis|emphysema|COPD"] GI:[checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive belching|excessing flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin"] Urinary:[checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine|UTI|stones|prostate issues"] Msk:[checklist name="MSK_list" value="joint pain|back pain|muscle problems|swelling|stiffness|decreased ROM|broken bone|arthritis|gout|difficulty walking"] Skin:[checklist name="Skin" value="rashes|other skin complaints"] Peripheral Vascular: [checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins|venous stasis"] Neuro: [checklist name="Neuro_list" value="HA|migraines|seizures|LOC/fainting|paralysis|weakness|muscle spasms|tremor|numbness|tingling|involuntary movement|incoordination|memory deficits"] Endocrine:[checklist name="Endo" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes"] Immunologic: [checklist name="imm" value="TB|hepatitis|recurrent infections"] Hematologic:[checklist name="hemm" value="anemia|easy bleeding"] Psychiatric:[checklist name="Psych" value="anxiety|muscle tension|depression|thoughts of suicide|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis"] PMHx: [textarea name="PMHx"] Surg Hx: [textarea name="surg_hx"] Family Hx: [textarea name="fam_hx"] Allergies: [text name="allergy_box"] Objective Diagnostics: [textarea name="Diagnostics_box" default="Labs"] Vital Signs Temp [text name="temp" default=""]F, BP[text name="BP" default=""], HR [text name="HR" default=""], RR [text name="RR" default=""], SpO2 [text name="variable_1" default=""]% Physical Exam General: [textarea name="general" default=""] [checkbox name="GeneralPE" value="A&Ox4.|A&Ox3. |A&Ox2.|A&Ox1. |Anxious. |Tearful. |Lethargic. |Alert. |Does not appear to be in any acute distress. |Well nourished. |Obese. |Thin. |Frail. |Unkept. |Well-groomed. |Appears stated age."] Neuro: [textarea name="variable_22" default=""] [checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Sensation is decreased in BLE. |Sensation is decreased b/l feet. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed."] Head: [checklist name="head" value="Head is normocephalic and atraumatic. |Head is w/o tenderness, visible or palpable masses, and depressions. |Hair is of normal texture and distribution."] Eyes: [checklist name="eyes" value="Conjunctiva are clear w/o excudates or hemorrhage. |Sclera is non-icteric. |EOM intact. |PERRLA."] Ears:[checklist name="ears" value="Bilateral external ear canals are non-tender and w/o swelling. |Hearing is grossly intact. |Difficulty hearing. | Hearing aide present. |TM is normal in appearance w/ normal landmarks and cone of light."] Nose: [checklist name="nose" value="Clear nasal discharge. |Purulent nasal discharge. |No nasal discharge. |Nares patent b/l. |Nasal mucosa is pink and moist."] Throat:[checklist name="throat" value="Oral mucosa is pink and moist. |No inflammation, swelling, exudate, or lesions noted. |Good dentition. |Poor Dentation. |Dentures present. | Partials present. "] Neck:[checklist name="neck" value="Supple, non-tender, w/o lymphadenopathy, masses or thyromegaly. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD. |HEENT exam not performed."] Cardio: [textarea name="variable_25" default=""] [checkbox name="CardpulmPE" value="Heart rate normal. |Tachycardia. |Bradycardia. |Regular rhythm. |Irregular rhythm. |Irregularly irregular rhythm. |Normal S1 and S2, no S3/S4. |S1/S2,S3 noted, no S4. |S1/S2, no S3, S4 noted. |S3 and S4 noted. |No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. |Chest wall is symmetric and w/o deformity or signs of trauma. |No edema noted. |Non-pitting BLE. |+1 pitting BLE. |+2 pitting BLE. |+3 pitting BLE. |Peripheral pulses are 2+ throughout. |Peripheral pulses are diminshed."] Respiratory: [textarea name="resp" default=""] [checkbox name="RespiratoryPE" value="No signs of respiratory distress. |Normal effort. |Labored breathing. |No increased work of breathing. |Tachypena. |Hypopena. |Rales/Rhonci. |Inspiratory wheezes b/l. |Expiratory wheezes b/l. |Inspiratory/Expiratory wheezes b/l. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Diminished breath sounds b/l. |Dyspena on exertion. ||Pulmonary exam not performed."] GI: [textarea name="variable_26" default=""] [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation. |Umbilicus is midline w/o herniation. |Normal BS in all four quadrants. |No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed."] GU: [textarea name="variable_27" default=""] [checkbox name="GUPE" value=" Normal rectal sphincter tone. |No external masses or lesions. |Stool is normal in appearance. |External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |Exam deferred. "] Integumentary: [textarea name="variable_23" default=""] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|Appropriate color for ethnicity. |Nail beds are pink. |No cyanosis or clubbing. |Clubbing of the fingers noted. |Integumentary exam not performed."] Musculoskeltal: [textarea name="variable_28" default="Insert abnormalities or delete this text to remove."] [checkbox name="PeriVascPE" value="Spine is in normal alignment. | Spine is kyphotic. | Lordosis curvature noted.| Scolosis noted. |UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Decreased ROM in UE.| Decreased ROM in LE.| Decreased ROM in all four extremites. |Contractures. |No contractures noted. |Curvature of the fingers noted - Mallet fingers. |Curvature of the fingers noted - Swan neck. | Curvature of the fingers - boutonniere deformity. |Muscle strength is 5/5 b/l. |Decreased muscle strength. |Gait independent. | Unsteady gait. | Utilizes cane or walker. |Utilizes wheelchair. | Non-ambulatory. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed."] Psych: [textarea name="variable_29" default="Insert abnormalities or delete this text to remove."] [checkbox name="MSE" value="Appropriate mood and affect. |Pt is cooperative. |Conversant. |Confused. |Flat. |Distrustful. |Delusional. |Agitated.| Lethargic. |Unwilling to engage. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No suicidal thoughts or behavior. |MSE not performed."] Labs: [textarea name="labss"] Imaging: [textarea name="imaging"] Other: [textarea name="other"] ---------- ASSESSMENT ---------- [textarea name="assessment_text_area"] ICD-10 Diagnoses: [textarea name="ICD10dx"] Discussion ---- PLAN ---- Treatment: [textarea name="tx"] Patient Education: [textarea name="PEdu"] Follow-Up: [textarea name="FU"] /e/Signed By: [text name="variable_30"] on [text name="variable_31"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.43, 80 form elements, 96 boilerplate words, 17 text boxes, 29 text areas, 1 dates, 9 checkboxes, 23 check lists, 1 drop downs, 325 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote