Adult – Full SOAP (text box)

CC: [text name="variable_1" default=" "]

Subjective
* HPI:[textarea name="variable_2" default=" Patient x.x. is a xx-year-old male/female who is an established patient with the clinic. / new patient to the clinic. Patient presents today for *****"]
[textarea name="variable_3" default="*****example: Hypertension: Patient presents for routine follow-up of hypertension. Medications include: none. Side effects: none. DENIES chest pain, palpitations, dizziness, or SOB. Patient does/does not regularly record BP readings. BP avgs from home log: 130s/80s."]
[textarea name="variable_4" default=" "]
[textarea name="variable_80" default="* Allergies: N.K.D.A."]
[textarea name="variable_5" default="* Medical History: No past medical history."]
[textarea name="variable_6" default="* Surgical History: None. "]
[textarea name="variable_58" default="* Family History:"]
[textarea name="variable_7" default="* Tobacco use: never"]
[textarea name="variable_8" default="* Drug use: Denies."]
[textarea name="variable_9" default="* Alcohol use: Rarely/ Socially."]
[textarea name="variable_53" default="* Medications: "]

* ROS
General/Constitutional: [textarea name="variable_10" default="Patient denies fever, chills, fatigue, sleep disturbance, night sweats, weight gain, weight loss, change in appetite. Overall health Good."]
Skin: [textarea name="variable_62" default="Patient denies itching, rash, or lesions. No changes to hair or nails."]
Ophthalmologic: [textarea name="variable_11" default="Patient denies visual changes, blurred vision, eye pain. No itching, redness or drainage."]
ENT: [textarea name="variable_12" default="Patient denies nasal congestion, nasal drainage, sore throat, ear pain, decreased hearing. No dysphagia. No sinus pain or pressure."]
Endocrine: [textarea name="variable_13" default="Patient denies cold intolerance, heat intolerance, frequent urination, excessive thirst, excessive hunger, hair loss. No hypoglycemia."]
Respiratory: [textarea name="variable_14" default="Patient denies cough, shortness of breath, dyspnea, wheezing, hemoptysis, or respiratory distress."] 
Cardiovascular: [textarea name="variable_15" default="Patient denies chest pain, chest pain with exertion, dyspnea on exertion, heart problems, irregular heartbeat, palpitations, orthopnea."]
Gastrointestinal: [textarea name="variable_16" default="Patient denies abdominal pain, nausea, vomiting, diarrhea, constipation, decreased appetite, heartburn, blood in stool. Hematology: Patient denies bleeding problems, easy bruising, or swollen glands."]
Genitourinary: [textarea name="variable_17" default="Patient denies frequent urination, difficulty urinating, painful urination, hematuria, or incontinence."]
Musculoskeletal: [textarea name="variable_18" default="Patient denies back or neck pain, joint pain, decreased ROM, redness or swelling to joints. No pedal edema. No myalgias. No CVA tenderness."]
Neurologic: [textarea name="variable_19" default="Patient denies balance difficulty , dizziness , visual changes, gait abnormality , loss of strength, headache, paresthesias. No change in speech."] 
Psychiatric: [textarea name="variable_20" default="Patient denies anxiety , depressed mood , difficulty sleeping. No panic attacks. No SI/HI. No change in appetite."]

Objective
* Vitals: HR [text name="variable_21" default=" "], RR [text name="variable_26" default=" "], Ht [text name="variable_24" default=" "], Wt [text name="variable_23" default=" "], BMI [text name="variable_25" default=" "], BP [text name="variable_22" default=" "], Spo2 [text name="variable_27" default=" "], Temp [text name="variable_25" default=" "]

* Physical Exam
-Skin: [textarea name="variable_28" default="warm, dry, no rashes, no suspicious lesions"]
-Head: [textarea name="variable_29" default="normocephalic, no scalp lesions."]
-Eyes: [textarea name="variable_30" default="PERRLA; Sclera-not injected, non icteric. No drainage. Lids are clear w/ no lesions."]
-Ears: [textarea name="variable_31" default="External (Bilateral): No redness, drainage, or lesions.; EAR CANAL (Bilateral) TMs dull w/ out effusion, no drainage, landmarks visible"]
-Oral Cavity: [textarea name="variable_32" default="mucosa moist, no lesions. Tongue midline, o lesions."]
-Nose: [textarea name="variable_33" default="nares patent, no lesions, no drainage, no signs of epistaxis. No sinus tenderness."]
-Throat: [textarea name="variable_34" default="clear, no erythema or exudate. Uvula midline. No swelling or redness to pharynx or tonsils."]
-Neck/Thyroid: [textarea name="variable_35" default="neck supple, full range of motion, no cerivacl lymphadenopathy, no JVD, no carotid bruit."]
-Lymph Nodes: [textarea name="variable_36" default="no lymphadenopathy"]
-Lungs: [textarea name="variable_37" default="clear to auscultation bilaterally, no wheezing or dyspnea."]
-Cardiovascular: [textarea name="variable_38" default="rate regular without murmurs, gallops, or rubs. PMI nondisplaced; no appearance of JVD"]
-Abdomen: [textarea name="variable_39" default="soft, non-tender, non-distended. round, soft, BX x4 active non-tender to palpation; no rebound tenderness, no organomegaly, no guarding."]
-Musculoskeletal: [textarea name="variable_40" default="ROM to all extremities/patient's expected normal; no joint deformities or swelling; (+) pedal pulse present-equal bilaterally. Cap refill <2sec. No pedal edema."]
-Neurologic: [textarea name="variable_41" default="Mental Status: alert and cooperative. Good eye contact. Thought processes are coherent with good insight. Oriented to person, place, and time. Motor: fair muscle bulk with fair tone. Strength: no weaknesses reported. Cerebellar: point-to-point movements intact. Sensory: no loss of sensation noted. Reflexes: intact."]

[textarea name="variable_42" default="*****this box can be used for labs/diagnostics/preventative health*****"]

ASSESSMENT / PLAN

[textarea name="variable_43" default=" "]
[textarea name="variable_44" default=" "]
[textarea name="variable_45" default=" "]
[textarea name="variable_46" default=" "]

Follow-up: [text name="variable_51" default=" "]
CC:

Subjective
* HPI:











* ROS
General/Constitutional:
Skin:
Ophthalmologic:
ENT:
Endocrine:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurologic:
Psychiatric:

Objective
* Vitals: HR , RR , Ht , Wt , BMI , BP , Spo2 , Temp

* Physical Exam
-Skin:
-Head:
-Eyes:
-Ears:
-Oral Cavity:
-Nose:
-Throat:
-Neck/Thyroid:
-Lymph Nodes:
-Lungs:
-Cardiovascular:
-Abdomen:
-Musculoskeletal:
-Neurologic:



ASSESSMENT / PLAN






Follow-up:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 52 form elements, 49 boilerplate words, 10 text boxes, 42 text areas, 52 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: