SOAP NOTE, TEMPLATE

SOAP NOTES

Patient initials and age:

Chief complaint:

History of present illness:

Past medical history:
1.

Family history:
1.

Social history:
1.

Medications:
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Immunizations:
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Allergies:
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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:

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Co-existing medical diagnosis:

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Differential diagnoses:

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PLAN:

Diagnostic plan:

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Treatment Plan:

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Education Plan:

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