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
HPI paragraph, as well as, the Past
coffee on an empty stomach before taking his Nexium. He denies
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.
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REMINDERS:
Always provide the specific name
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

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

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

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.

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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.
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

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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
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.
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SUBJECTIVE
Chief Complaint: Patient is an 11-year-old male with a history significant for
obesity who presents to the clinic today for a well child check
up.

History of Present Illness: Obesity

Patient’s mother noted that the patient has been doing well but
had noticed that he has been having excessive hunger and
trouble concentrating that has been going on for the past 5
months. He does not play sports and is noted to be not super
active. He is always hungry and after he eats he doesn’t feel
full. He does not eat healthy foods. Thus his mother tries to
make sure that he has vegetables and low-sugar contained
foods for dinner. But his mother is not able to maintain a
healthy meal ready on a regular basis due to a hectic work
schedule and instead picks up at Chick Fil A on the way home.
Patient drinks water and gatorade, but not a lot of soda.

Dental
Patient had a recent visit with his dentist as stated by his
mother. He brushes his teeth twice a day on a regular basis.

Concentration
Patient’s mother noted that he has trouble focusing at school
or doing one task for a long period of time. These symptoms
were noted for the past 7 months which had started towards
the end of the last school year. His teachers have been saying
he takes a long time to complete one task. His mother noticed
that his grades have been slipping too which was unusual as
he was claimed to be a straight A student but now was noted
to be getting B’s and C’s. Patient was known to have a good
friend group at school but recently seems to just want to play
video games and watch YouTube with a screentime of not
more than 2 hours a day. Patient is noted to finish his
homework but as per mother’s observation he seems so
distracted and would take a longer time to complete simple
assignments. He is noted to have weight gain and constant
hunger. He has no recent symptoms of fever, cough or mood
changes. Patient is allergic to peanuts. He has no medication
allergies. He has up to date immunizations. He is not currently
taking any medications. He takes children’s multivitamin as a
supplement.

Test Results: Patient has not undergone any laboratory examination or

imaging studies.
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Medications: Patient does not take any medications. He takes children’s
multivitamin as a supplement.

Allergies: Patient is allergic to peanuts. He has no medication allergies.

Past Medical History: Past medical history is significant for obesity.

Past Surgical History: Patient had undergone appendectomy at 9 years old.

Family History: His mother has Diabetes Mellitus Type II and is maintained on
insulin.

Social History: He used to have a good friend group at school but recently
prefers to spend most of his time playing video games and
watching YouTube with a screentime of not more than 2 hours
a day. He does not play sports and is noted to be not super
active.

Review of Systems

Constitutional: +weight gain, fever, -fatigue, -night sweats

Eyes: -vision changes

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

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

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

Gastrointestinal: -heartburn, -nausea, -vomiting, -diarrhea, +constant hunger,

-change in bowel habits

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

Musculoskeletal: -myalgia, -arthralgia

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

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

Psychiatric +mood changes, +trouble concentrating, +inattention

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

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

Immunologic: +allergic to peanuts

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OBJECTIVE
Physical Exam

Vitals:

Constitutional: Well-developed. No acute distress. Obese with a BMI of 31 at

95th percentile

Eyes: Conjunctivae are non-injected. EOMI. PERRLA.

Ear/Nose/Throat:

Neck: Supple. No swollen lymph nodes.

Cardiovascular: Regular rate and rhythm. No murmur, rubs, or gallops. Normal

radial pulses bilaterally.

Respiratory: Minimal labored breathing noted. Chest rise is symmetric. No

wheezes, rales or rhonchi. Clear to auscultation bilaterally.

Breast:

Gastrointestinal: Soft and nontender. No distension.

Genitourinary:

Musculoskeletal: Normal ROM. 2cm bruise on right knee. No swelling. No

rashes.

Integumentary/Skin:

Neurological: He is alert and oriented. Sensation is intact to light touch

Psychiatric: Normal mood and affect.

Endocrine:

Hematologic/Lymphatic:

Immunologic:
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ASSESSMENT
Diagnosis 1: E66.9 Childhood obesity, bmi 95-100 percentile

Diagnosis 2: F90.0 Attention-deficit hyperactivity disorder, predominantly

inattentive type

Diagnosis 3:

Diagnosis 4:

Diagnosis 5:

PLAN
Diagnosis 1: E66.9 Childhood obesity, bmi 95-100 percentile
Patient is instructed to incorporate a lot of fruits and
vegetables into the diet. If he chooses to have a fast food
pick up, patient is advised to choose healthier options like
grilled chicken, salads, fruits and milk. Recommended to
have physical activity by joining some club sports at school
that the patient would be interested in or to try taking a
walk with his mom around the neighborhood a couple of
times a week. Discussed the risk of developing diabetes if
weight gain is not controlled. Baseline laboratories to
monitor the risk of developing diabetes. Baseline CBC, CMP,
HbA1c.

Diagnosis 2: F90.0 Attention-deficit hyperactivity disorder, predominantly

inattentive type
Started on low dose Vyvanse 10mg a day. Patient’s mother
was instructed for the patient to have meals before intake of
medication as it typically eliminates hunger as a side effect
which would help with the patient’s increased appetite as well
as it would also give him some extra energy to stay active
throughout the day. Medication should be taken early in the
morning as it is a stimulant and avoid taking it late in the day
as it may affect the patient’s ability to sleep. Referral to a
psychiatrist was given. Followup in 2 weeks to monitor for the
need of any medication adjustments and to review the
laboratory results.
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Diagnosis 3:

Diagnosis 4:

Diagnosis 5: