SOAP NOTE, TEMPLATE

 

soap note

SOAP NOTES

Patient initials and age:

Chief complaint: 

History of present illness: 

Past medical history:
1.     

2.

3.

Family history:
1.

2.

3.

Social history: 
1.

2.

3.

4.

5.

Medications:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Immunizations:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Review of systems:

        General: 

        Integumentary: 

        HEENT: 

        Lymphatic: 

        Lungs/chest: 

        Cardiac: 

        Gastrointestinal: .

        Endocrine: 

        Genitourinary: 

        Musculoskeletal: 

        Neurological: 

        Psychiatric: 


 OBJECTIVE DATA:

         Vital signs:


Physical exam:

        General: 

        Mental status: 

        Integumentary: 

        HEENT: 

        Lymphatic system: 

        Lungs/chest: 

        Cardiac/vascular: 

        Abdomen: 

        Male genitalia, anus, and rectum: 

        Musculoskeletal system: 

        Neurological: 


 ASSESSMENT:

 Nursing diagnosis: 

1.     

All-inclusive medical diagnoses for this visit:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Co-existing medical diagnosis:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Differential diagnoses:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLAN:

 Diagnostic plan:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Treatment Plan:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Education Plan:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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