Endocrinology Outpatient Progress Note (SOAP)

Endocrinology Outpatient Progress Note (SOAP)

Date: [Date]

Patient: [Patient name]

DOB: [DOB]

Provider: [Provider name and credentials]

Visit Type: [New / Established], [In-person / Video / Telephone]

Subjective

Chief Complaint: [Chief complaint in condition-focused language]

Interval History: [Narrative of interval changes since last endocrine visit] (Include medication adherence and tolerability, relevant lifestyle factors, and intercurrent events. For new patients, include onset, trajectory, prior evaluations/treatments, and the clinical question. Document safety events such as hypoglycemia, falls, or fractures when relevant. Include brief direct quotes only when materially affecting management.)

Review of Systems: [Pertinent positives and negatives for systems relevant to problems addressed] (Only include systems actually reviewed. If ROS was limited, state the reason.)

Objective

Vitals: [BP, HR, weight, BMI; height if relevant] (Note if patient-reported for telehealth.)

Exam: [Focused examination findings tied to conditions addressed] (For telehealth, state "Limited exam due to video visit" and note observable findings. Include feet/injection sites for diabetes, thyroid/neck for thyroid disorders, posture/gait for bone disease as applicable.)

Data: [Key laboratory results, imaging, and diagnostic studies with dates] (Present as compact trends with dates and sources. Flag guideline-relevant tests due but unavailable, e.g., "No recent UACR—ordered today.")

Device Data: [CGM/pump/AID data if applicable] (Include device type, date range reviewed, data coverage %, mean glucose, GMI, %CV, TIR, TAR, TBR. Summarize actionable patterns and note any setting changes. Reference attached reports such as AGP. Omit section if no device data reviewed.)

Assessment

(List each endocrine problem addressed in order of clinical priority. Do not document tests or exams as normal unless actually reviewed.)

[Problem 1]: [Diagnosis]

[Status: controlled / uncontrolled / at goal / above goal / stable / worsening] — [Key supporting data with dates; relevant complications or risk context]

[Problem 2]: [Diagnosis]

(Include only problems addressed today. Use same structure.)

[Additional problems as needed]

Plan

(Organize by problem, mirroring Assessment order. If information is missing, document a contingency plan rather than leaving blank.)

[Problem 1]: [Diagnosis]

[Diagnostics ordered with timing; medication changes with dose and rationale; device/setting adjustments; monitoring instructions and contact thresholds; counseling and shared decision-making summary; referrals and care coordination] (Include only applicable elements for each problem.)

[Problem 2]: [Diagnosis]

[Plan elements as applicable]

[Additional problems as needed]

Follow-up: [Interval] [In-person / Video / Telephone] (Include pre-visit requirements such as labs or device upload timing.)

Time-based billing: [Total minutes] (Include only if using time-based E/M coding.)