Aerospace Medicine Clinic SOAP Note

Patient: [name, DOB/age, sex per local policy]

Date/Time: [encounter date and time]

Clinician: [name and credentials]

Visit Type: [acute problem / follow-up / administrative-clearance / post-incident / return-to-flight]

Operational Context: [role (aircrew/ATC/UAS/maintenance/other safety-sensitive), platform if relevant, current flight status (flying/grounded/restricted), and whether G/altitude/pressure exposure is relevant to this visit; state "Not applicable" if non-operational] (If any element is unknown, document "Unknown/not obtained" with reason.)

Subjective

Chief Complaint: [patient's own words; prioritize most operationally impactful complaint first] (If multiple complaints, list in order of operational risk.)

History of Present Illness:

[One-liner: age, role, presentation, and operational trigger if applicable]

[Timeline with dates/times relative to flight or duty; operational context at onset; incapacitation-relevant symptoms such as syncope, vertigo, chest pain, neurologic deficits, or visual disturbance; recent exposures including altitude chamber, diving, hypoxia training, or fatigue/sleep debt; self-treatment and response; red flags] (Include only pertinent positives/negatives actually assessed.)

Pertinent ROS: [systems relevant to chief complaint and aeromedical risk—particularly neuro, cardiopulmonary, ENT, sleep/fatigue] (Do not use "all other systems negative" unless a complete ROS was performed.)

Medications: [current Rx, PRN, OTC, supplements with doses; recent changes; aeromedically relevant side effects such as sedation, dizziness, or visual changes] (If medication reconciliation not completed, state reason.)

Allergies: [allergen and reaction type, or NKDA] (If unknown, document "Unknown/not obtained" with reason.)

Relevant History: [prior similar episodes, conditions affecting incapacitation risk, existing waivers/restrictions, substance use relevant to duty] (Include only visit-pertinent items, not entire problem list.)

Objective

Vitals: [BP, HR, RR, Temp, SpO2 as relevant; orthostatics if indicated] (Include units. If any vitals not obtained, state reason.)

Exam: [pertinent findings by system, prioritizing neuro, cardiovascular, ENT, vision, and pulmonary for aerospace relevance; document findings supporting or refuting key differentials and aeromedical risk] (If a component is deferred, state reason.)

Data: [labs, imaging, EKG, audiogram, vision testing, spirometry, external records—include dates and key results for completed studies] (Do not list pending tests here.)

Assessment

(Present as a numbered problem list ordered by operational/safety risk first, then medical severity.)

1. [Problem]: [Diagnosis or working diagnosis] ([acute / subacute / chronic]; [improving / stable / worsening])

   [Key supporting evidence from S/O in 1–2 sentences]

   Aeromedical risk: [incapacitation risk, recurrence probability, medication effects, susceptibility to G/altitude/pressure]

   Differential: [if uncertain; include "can't miss" conditions considered]

(Add additional problems as needed, following same format.)

Fitness Determination: [Fit (no restrictions) / Fit with restrictions / Not fit (grounded) / Deferred pending evaluation] (Provide brief justification. If deferred, state specific pending items.)

Plan

(Organize by problem number.)

1. [Problem 1 Plan]: [diagnostics ordered, therapeutics with rationale, performance-impact counseling for any impairing medication including ground trial or no-fly interval, referrals, patient education on self-grounding warning signs, follow-up timing]

(Add additional problem plans as needed.)

Flight/Duty Disposition (Required if any operational restriction applies):

• Disposition: [no restriction / restricted / grounded]
• Restrictions: [specific restrictions—e.g., no fly, no safety-sensitive duty, no NVG, no high-G, no pressure changes]
• Effective: [start date/time] through [end date/time or review date]
• Return-to-duty criteria: [symptom-free interval, medication washout period, required testing, specialist clearance]
• Clearance authority: [who can return member to full duty]
• Counseling: [document patient advised of self-grounding responsibilities and acknowledged understanding]