SOAP NOTE

SOAP NOTE

Subjective

History of Present Illness
Onset
Location
Duration
 
Changes with any specific activities?
What makes it worse?
What makes it better?
 
Does it come and go?
How bothersome is the problem?
Any other concerns?
 
Medical History
Diagnoses
Diagnoses
Diagnoses
 
Social History
Work
Drugs/ETOH/Smoking
Family (Married)
Stress levels
 

Objective

Allergies (Medications or Food) | and | Description of reaction
Vital Signs
Blood Pressure
Pulse
Resp
Temp
O2 Sats
Pain
 

Assessment

Diagnosis List | Problem List

Plan

Plan
Patient Education
Follow Up
Consent(Required)

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