SUBJECTIVE

CAUTION: This page needs to be reviewed and categorized.
PROGRESS NOTE FOR DATE OF SERVICE: [date name="DOS"]
Patient Name: [text name="NAME"]
Date of Birth: [text name="DOB"]
Total Time: [text name="TIME"] - minute follow up E/M, medication management, coordination of care and    psychotherapy


SUBJECTIVE
Chief Complaint: [text name="NAME"] presents today for follow up [textarea name="CC"]
History of Present Illness:    
[textarea name="HPI"]
Mental Health Updates:
[textarea name="MHUPDATE"]
Discussed with [text name="NAME"], [textarea name="DISCUSSION"]
Social History (recent/updates):
[textarea name="SOCIAL"]
Family History (recent or past pertinent):
[textarea name="FAMILY"]
Medical & Surgical (recent updates): 
[textarea name="MEDSURG"]

REVIEW OF SYSTEMS:
Systems review discussed with the patient on the date of present    visit.
All historical data remain unchanged from intake H&P, with no recent new outside treatments or preventative    care reported, any pertinent updates and all related systems or constitutional changes are reserved and    provided as reported at present visit in the HPI above. 

H&P review: [date name="DOS"]
Reviewed pertinent aspects of history of present illness obtained at    the time of patient's intake: yes
Reviewed prior visit's pertinent findings at today's: yes
Recent educational, vocational, and social history updates: yes
Exceptions, updates & information discussed: see above 


OBJECTIVE
Mental Status Exam: [textarea name="MSE"]
Physical Exam:    [textarea name="PE"]

Vital    Signs:    
Height: [text name="ht"] Weight: [text name="wt"]
BP: [text name="b"]/[text name="p"] RESP: [text name="r"] HR: [text name="hr"]
PAIN LEVEL: [text name="pain"]/ 10

Labs requested: none at this time
PROGRESS NOTE FOR DATE OF SERVICE:
Patient Name:
Date of Birth:
Total Time: - minute follow up E/M, medication management, coordination of care and psychotherapy


SUBJECTIVE
Chief Complaint: presents today for follow up

History of Present Illness:

Mental Health Updates:

Discussed with ,

Social History (recent/updates):

Family History (recent or past pertinent):

Medical & Surgical (recent updates):


REVIEW OF SYSTEMS:
Systems review discussed with the patient on the date of present visit.
All historical data remain unchanged from intake H&P, with no recent new outside treatments or preventative care reported, any pertinent updates and all related systems or constitutional changes are reserved and provided as reported at present visit in the HPI above.

H&P review:
Reviewed pertinent aspects of history of present illness obtained at the time of patient's intake: yes
Reviewed prior visit's pertinent findings at today's: yes
Recent educational, vocational, and social history updates: yes
Exceptions, updates & information discussed: see above


OBJECTIVE
Mental Status Exam:

Physical Exam:


Vital Signs:
Height: Weight:
BP: / RESP: HR:
PAIN LEVEL: / 10

Labs requested: none at this time

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.09, 23 form elements, 176 boilerplate words, 12 text boxes, 9 text areas, 2 dates, 23 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: