SOAP Note Template

INSTRUCTIONS
Use the template on the following pages to construct your SOAP Note. Each section must be fully
documented.

Remember to “Make a Copy” of this document instead of requesting edit access.

HELPFUL TIPS
● Please pay close attention to the reminders highlighted in yellow in the SOAP Note as
they will help you create a better SOAP Note.
● ICD-10 Code Websites:
○ ICD10Data.com
○ ICD10CodeLookUp.com
○ Or any other ICD-10 code website that you prefer.
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EXAMPLE
SUBJECTIVE
REMINDERS:
This should be the most thorough and detailed part of the SOAP Note since it provides context for the rest of the
patient encounter.

Chief Complaint: Patient is a 57-year-old male with a history of arthritis, chronic back
pain, and GERD who presents to the clinic today for an annual
physical exam.

History of Present Illness: Arthritis

Overall, he is in good health. He notes consistent pain in his bilateral
REMINDERS: knees described as a “stiffness.” His knee pain is worse in the
Separate each of the patient morning upon waking, but improves throughout the day. He states
complaints into separate
that his knee pain is worse after returning home from work and notes
paragraphs with a problem header
listed. associated achy pain and swelling. He does a lot of bending and
lifting at work, which contributes to his pain. He has been taking over
Make sure to include all HPI the counter Aleve, which has provided him moderate relief. Patient
elements that are discussed. also notes chronic back pain described as soreness and throbbing
(Onset, Timing, Location, Severity,
pain. He denies any recent injury, numbness, or weakness.
Modifying Factors, Quality,
Associated Symptoms, and
Context) GERD
Patient notes his GERD has been well managed with Nexium 40 mg
If past medical history is pertinent once daily. He experiences episodes of heartburn when he drinks
to the complaint, include this in the
coffee on an empty stomach before taking his Nexium. He denies
HPI paragraph, as well as, the Past
Medical History section. any chest pain, palpitations, shortness of breath, urinary complaints,
or headaches.
Provide as much detail as possible
as this is what is guiding the
provider with their medical
decision making (physical exam to
do, labs/imaging to order,
diagnoses, plan, etc).

Test Results: Patient had an MRI on October 12, 2022 which showed degenerative
disc disease.

Per review of labs, total cholesterol was 180, HDL 62, LDL 98,
triglycerides 102. Cholesterol levels, CBC, and urinalysis are all
within normal limits. CMP is normal, except for an elevated glucose
of 140. HbA1c of 5.9, which puts the patient in the pre-diabetic range.
This is elevated from his last HbA1c done 3 months ago. PSA value
of 1.0 is within normal limits.

Medications: He is currently taking Nexium 40 mg once a day for GERD. He is

taking over the counter Aleve for arthritis and chronic back pain.
REMINDERS:
Always provide the specific name
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of the medication (if it is stated). For
example, you should not simply
type “Patient is on cholesterol
medication.”

Allergies: Patient has no known drug allergies.

Past Medical History: Past medical history is significant for arthritis, chronic back pain, and
GERD. His last colonoscopy was in 2019 and he is not due until
REMINDERS: 2029.
Always use proper medical
terminology and write in complete
sentences. (Ex: high blood
pressure = hypertension)

Past Surgical History: He underwent right rotator cuff surgery in 2016, but has not had any
new procedures since his last visit, except for his 2019 colonoscopy.

Family History: His mother had type II diabetes mellitus and his father had
hypertension.

Social History: Patient denies tobacco use or drug use. He admits to drinking
occasionally, but has not consumed more than 4 drinks in one day in
the past year. Patient is currently working as a mechanic. He is active
and does moderate exercise that includes cycling and the use of a
Peloton.

Review of Systems

REMINDER:
All symptoms mentioned in the HPI should be included in the ROS and in their appropriate body system.

Constitutional: -night sweats, -fevers, -fatigue

Eyes: -vision changes

Ear/Nose/Throat: -tinnitus, -nasal irritation, -sore throat

Cardiovascular: -chest pain, -palpitations, -chest tightness

Respiratory: -shortness of breath, -wheezing, -cough

Gastrointestinal: +heartburn, -nausea, -vomiting, -diarrhea, -change in diet, -change in

bowel habits

Genitourinary: -urinary symptoms, -pelvic pressure, -flank pain

Musculoskeletal: +joint pain, +back pain, +joint swelling

Integumentary/Skin: -skin texture changes, -skin lesion, -rash

Neurological -numbness, -weakness, -headaches, -tremors, -lightheadedness

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Psychiatric -mood swings, -anxiety

Endocrine: -unusual cravings, -cold intolerance, -excessive sweating

Hematologic/Lymphatic: -swollen lymph nodes, -easy bruising

Immunologic: -seasonal allergies, -hives

OBJECTIVE
Physical Exam

Reminders:
Always use proper medical terminology. (Ex: redness = erythema)
Each physical exam findings should be documented in its associated body system.

Vitals: T 97.7, HR 86, RR 20, BP 122/82, O2 98%, BMI 28.0

Constitutional: Healthy appearing. Well-developed. No acute distress. Mildly

overweight with a BMI of 28.0.

Eyes: Conjunctiva is pink. Sclera is white. Iris is intact and round. Vision is
grossly intact. EOMI. PERRLA.

Ear/Nose/Throat: Ears: Nontender with ear canals pink with no excessive cerumen
Pearly grey tympanic membrane. Hearing grossly intact.
Nose: Nares intact. No deformities. Nontender sinuses.
Throat: Oral mucosa is pink and moist. No dental deformities, oral
sores, signs of infection or bleeding. Tongue is intact. Palate intact.
Uvula midline. +1 grade tonsils. Swallowing reflex and gag reflex are
intact.

Neck: Supple. Full ROM. No carotid bruits. No palpable masses, Trachea is

midline.

Cardiovascular: Regular rhythm and rate. No murmur. No rub. No gallop. S1 and S2

are normal.

Respiratory: No respiratory distress. No wheezes. No rales. No rhonchi. No

tachypnea. Clear to auscultation bilaterally. Chest rise is symmetric.

Breast: No skin changes. Nontender to palpation. No gynecomastia.

Gastrointestinal: Soft and nontender. No distension. Bowel sounds normal. No

masses. No hepatosplenomegaly.

Genitourinary: Deferred.

Musculoskeletal: Upper extremity muscle strength and sensation are normal bilaterally.
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Mild bilateral knee edema and slightly diminished active and passive
ROM. No knee tenderness. No knee crepitus. Right knee erythema.

Examination of the back shows generalized tenderness on palpation

of the musculature surrounding the lumbar spine, more so on right
than left. No spinous tenderness. Full spinal ROM.

Integumentary/Skin: Warm and dry. Skin is intact. No open lesions, bruises, or rashes.

Neurological: He is alert and oriented. Normal motor strength and tone. Cranial
nerves II-XII intact. Balanced gait. Sensations of extremities intact.

Psychiatric: Normal affect. Normal mood. Recent memory intact.

Endocrine: Non-tender neck and no masses. No abnormal hair growth or loss.

Hematologic/Lymphatic: Non-tender lymph nodes.

Immunologic: Deferred.

ASSESSMENT
Reminder:
All diagnoses discussed in the transcript should be in the note.

Always provide the alphanumeric ICD-10 and provide the full medical condition name for that ICD-10 code. For
example, K21.9 GERD is not correct – it should be K21.9 Gastro-esophageal reflux disease without esophagitis.

Diagnosis 1: M51.36 Other intervertebral disc degeneration, lumbar region

Diagnosis 2: K21.9 Gastro-esophageal reflux disease without esophagitis

Diagnosis 3: M17.0 Bilateral primary osteoarthritis of knee

Diagnosis 4: R73.03 Prediabetes

Diagnosis 5: Z00.01 Encounter for general adult medical examination with

abnormal findings

Diagnosis 6: Z68.28 Body mass index (BMI) 28.0-28.9, adult

OR, you could use E66.3 Overweight

PLAN
REMINDERS:
Every assessment should have a corresponding plan listed.

List the assessment followed by the details of the plan which should always include medical-decision making. For
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example, if the provider decides the patient should stop taking a medication (Tylenol) and start taking a different
medication (Ibuprofen), then you should document the reason for this. The doctor would have explained the
reasoning for this to the patient; so, it should be easy to include.

Diagnosis 1: Other intervertebral disc degeneration, lumbar region

Results of MRI show concern for degenerative disc disease.
Instructed the patient to alternate ice and heat and take OTC Tylenol,
Aspirin or Aleve for pain control. If pain continues to worsen or begins
to impact daily living, the patient is instructed to call the clinic and we
will request a referral to an orthopedic surgeon to discuss surgical
treatment options.

Diagnosis 2: Gastro-esophageal reflux disease without esophagitis

Patient doing well on Nexium 40 mg. Will refill Nexium for another 3
months. Recommend patient take his Nexium prior to drinking his
morning coffee.

Diagnosis 3: Bilateral primary osteoarthritis of knee

Patient instructed to take OTC Tylenol, Aspirin, or Aleve for pain
control. Will refer to an orthopedic surgeon for evaluation and
management if symptoms worsen.

Diagnosis 4: Prediabetes
Patient with a HbA1c of 5.9, which is elevated compared to previous
HbA1c 3 months ago. Patient is pre-diabetic. Repeat HbA1c lab
again in one month. Patient instructed to reduce sugar and
carbohydrate intake.

Diagnosis 5: Encounter for general adult medical examination with abnormal

findings
PSA value of 1.0 within normal limits. Patient’s last colonoscopy was
in 2019. He is not due for a repeat screening until 2029. Follow up
appointment in 3 months.

Diagnosis 6: Body mass index (BMI) 28.0-28.9, adult

Patient instructed to increase physical activity. Recommend a weight
reduction of 3 to 5 pounds prior to next visit.

SUBJECTIVE
Chief Complaint: Patient presents today for

History of Present Illness:

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Test Results:

Medications:

Allergies:

Past Medical History:

Past Surgical History:

Family History:

Social History:

Review of Systems

Constitutional:

Eyes:

Ear/Nose/Throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary/Skin:

Neurological

Psychiatric

Endocrine:

Hematologic/Lymphatic:

Immunologic:

OBJECTIVE
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Physical Exam

Vitals:

Constitutional:

Eyes:

Ear/Nose/Throat:

Neck:

Cardiovascular:

Respiratory:

Breast:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary/Skin:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Immunologic:

ASSESSMENT
Diagnosis 1:

Diagnosis 2:

Diagnosis 3:

Diagnosis 4:
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Diagnosis 5:

PLAN
Diagnosis 1:

Diagnosis 2:

Diagnosis 3:

Diagnosis 4:

Diagnosis 5: