Posted: April 25th, 2025
SOAP NOTE
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
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SOAP NOTE TEMPLATE
Review the Rubric for more Guidance |
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Demographics | ||||||||||||||||||||||
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Chief Complaint (Reason for seeking health care) |
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History of Present Illness (HPI) |
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Allergies |
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Review of Systems (ROS) |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: |
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Vital Signs |
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Labs |
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Medications |
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Past Medical History |
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Past Surgical History |
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Family History |
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Social History |
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Health Maintenance/ Screenings |
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Physical Examination |
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Diagnosis |
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Differential Diagnosis |
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ICD 10 Coding |
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Pharmacologic treatment plan |
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Diagnostic/Lab Testing |
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Education |
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Anticipatory Guidance |
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Follow up plan |
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Prescription |
See Below (scroll down) |
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References |
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Grammar |
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EA#: 101010101 STU Clinic LIC# 10000000 |
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Tel: (000) 555-1234 FAX: (000) 555-12222 |
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Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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