SOAP Note

Name: [text name="variable_1" default=""]
Age: [text name="variable_2" default=""]

**Subjective**
Chief complaint: [text name="variable_3" default=""]

History of present illness: 
[textarea name="variable_4" default="Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Times,"]

Review of systems:
-General:[textarea name="variable_5" default=" Denies fever or chills, fatigue, malaise, or weight changes."]
-HEENT:[textarea name="variable_6" default=" Patient denies headaches, vision changes, rhinorrhea, sore throat or mouth pain."]
-Cardiac:[textarea name="variable_7" default=" Denies chest pain, palpitations, or edema."]
-Pulmonary:[textarea name="variable_8" default=" Denies shortness of breath, cough, or change in sputum production."]
-GI:[textarea name="variable_9" default=" Denies nausea or vomiting, abdominal pain, diarrhea or constipation, melena, or change in appetite."]
-GU:[textarea name="variable_10" default=" Denies dysuria, hematuria or incontenance."]
-Musculoskeletal:[textarea name="variable_11" default=" Denies myalgias, arthralgias, weakness, numbness or tingling."]
-Dermatologic:[textarea name="variable_12" default=" Denies rashes or erythema."]
-Neurologic:[textarea name="variable_13" default=" Denies seizures or changes in sensation."]
-Psychiatric:[textarea name="variable_14" default=" Denies depression, anxiety or mental health concerns. Patient is not suicidal."]
-Endocrine:[textarea name="variable_15" default=" Patient denies polyphagia, polydipsia, polyuria or heat/cold intolerance."]
-Hematologic/lymphatic:[textarea name="variable_16" default=" Denies abnormal bleeding/bruising."]

Past medical history: 
[textarea name="variable_17" default=""]

Past surgical history:
[textarea name="variable_18" default=""]

Allergies:[textarea name="variable_19" default=""]

Medications:
[textarea name="variable_20" default=""]

Social history:
Occupation - [text name="variable_21" default=""]
Living situation - [text name="variable_22" default=""]
Tobacco - [text name="variable_23" default=""]
Alcohol - [text name="variable_24" default=""]
Illicit drugs - [text name="variable_25" default=""]

Family history:
Mother - [textarea name="variable_26" default=""]
Father - [textarea name="variable_27" default=""]
Other - [textarea name="variable_29" default=" NA"]


**Objective**
Vital signs: 
T - [text name="variable_30" default=""] F
BP – [text name="variable_31" default=""] mm Hg
HR - [text name="variable_32" default=""] bpm
RR - [text name="variable_33" default=""] rpm
SaO2 - [text name="variable_34" default=""]%

Physical examination
-General:[textarea name="variable_35" default=" Patient is alert and oriented, Patient well developed, well nourished, cooperative, and appears to be in no acute distress."]
-HEENT: [textarea name="variable_36" default=" Normocephalic, EOM intact, PERRLA, anicteric, no injection, fundus WNL, no papilledema, tympanic membranes intact, non-inflamed, no congestion, no nasal discharge. Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly." 
-Cardiovascular: [textarea name="variable_37" default=" 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."]
-Pulmonary: [textarea name="variable_38" default=" Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
-Abdominal: [textarea name="variable_39" default=" Positive bowel sounds in all 4 quadrants. Soft, non-distended, non-tender. No guarding or rebound. No masses."]
-Neurological: [textarea name="variable_40" default=" CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
-Musculoskeletal: [textarea name="variable_61" default=" Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
-Extremities: [textarea name="variable_62" default=" No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
-Lower Extremities: [textarea name="variable_63" default=" 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."]
-Skin: [textarea name="variable_64" default=" Skin normal color, texture and turgor with no lesions or eruptions."]
- Psychiatric: [textarea name="variable_65" default=" 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."]

Significant Laboratory Values:[textarea name="variable_41" default=""]

Radiology:[textarea name="variable_42" default=""]

Microbiology:[textarea name="variable_43" default=""]


**Assessment**
[textarea name="variable_44" default=""]

Problem List:
[textarea name="variable_45" default=""]

Differential Diagnosis:
[textarea name="variable_46" default=""]



**Plan**
Diagnostics:
[textarea name="variable_47" default=""]

Education:
[textarea name="variable_48" default=" The above social history, allergies, medications, past medical history, were reviewed & updated at today's visit. Laboratory results were reviewed and discussed. Patient educated on appropriate health maintenance and screenings appropriate for age and gender. Educated patient on appropriate vaccination and when they are due. "]

Treatment/Orders:
[textarea name="variable_49" default=""]

Referral:
[textarea name="variable_51" default=""]

Goals:
[textarea name="variable_52" default="1. We will evaluate patients test results/symptoms and devise a diagnosis and appropriate treatment course for patient. 2. Patient will complete needed testing/imaging/diagnostics. 3. Patient will not have an adverse event before diagnosis can be completed. 4. Patient will continue medication/treatments as instructed and will not have adverse effects associated with them. "]

**Health maintenance**
Screening:
- Appropriate Screenings for Age/Sex: [textarea name="variable_66" default=" UTD"]  

Vaccinations:
- Flu vaccine: [text name="variable_54" default=""]
- Pneumococcal: [text name="variable_55" default=""]
- Td/Tdap: [text name="variable_56" default=""]

Counseling Given On:
- Smoking and alcohol cessation and abstaining from substance abuse
- Driving with a seatbelt 
- Safe sex practices
- Regular exercise, i.e., low impact, stationary bike, swimming
- Medication compliance
- Weight reduction
- Dietary counseling: low-fat diet, decrease whole dairy products (whole milk, cheese, and butter), fatty meats, and fried foods. Eat more fruits, vegetables, whole-wheat breads, lean chicken, and fish (such as salmon or tuna).  Attempt at counting calories, use a calorie tracker such as MyFitnessPal, strive for 2700 kcal per day, small frequent meals, and avoid concentrated sweets.

RTC: [text name="variable_60" default="": Education: Treatment: Follow-Up: Referral: Goals: "]