Acute Office Visit SOAP note – Student Template edited 1.7.

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Patient Name: (use initials)
Date: Time:
Faculty Evaluator:
Small Group Leader:
Medical Student name:
Subjective
Chief Complaint

History of Present Illness (include opening statement with Patient ID)

Past History
Chronic Medical Illnesses (include duration of each illness):
Mental Health Issues (include duration of each illness):
Hospitalizations/Accidents (include date, reason):
Surgical History (include dates, indications, types of surgery, complications):
Ob-Gyne History (gravida/para status, last menstrual period, contraceptive use, condoms):
Health Care Maintenance (include dates of last PCP visit, age-specific screening tests and immunizations):

Medications (include name, dose, route and frequency; also add duration if pertinent to case):

Drug / Food Allergies

Social History

Family History

Review of Systems

Objective
Physical Exam (only include applicable exams)
Vital Signs & Body Measurements: T ⁰ F BP mmHg RR bpm HR bpm Wt lbs Ht ft, in
General survey
Skin
HEENT
Neck
Lymph nodes
Thorax/Lungs
CV
Breasts (females)
Abd/Rectal:
PV/Extremities:
MSK
Neuro
Psyche
Genitourinary

Office testing: include results of pregnancy test, strep test, EKG, Xrays done in the office.
Assessment
Case Summary

Problem List
1.
2.
3.
4.

* Likely diagnosis (include supporting evidence)

1.

* Differential Diagnosis (include supporting evidence for and against diagnosis)

1.
2.

Plan

1. Diagnostic Plan
1.
2.
3.

2. Therapeutic Plan
1.
2.
3.

3. Patient Education
1.
2.
3.

4. Follow up
1.
2.

Signature
Print Name, Medical School Level (MS II) and UMHS
If the patient presents with multiple unrelated diagnoses (issues), include a likely diagnosis and differential
diagnosis discussion for each issue separately. You may, however, list the plan all together under a single
plan section.