Family Medicine SOAP Note

Date of Service: [Date]

Patient: [Patient name]

Provider: [Provider name, credentials]

Visit Type: [new / established]; [in-person / telehealth]

Chief Complaint: [Brief reason for visit in patient's words or follow-up focus]

Total Time: [Total minutes] (Include only if billing by time; record a specific number.)

Subjective

(Organize by problem when multiple issues are addressed. Use patient-readable language. Document only what was obtained today.)

[Problem 1]: [Brief problem label]

[Status since last visit; key symptoms with onset, duration, frequency, severity, and context; relieving/exacerbating factors; response to prior treatments; adherence and barriers if relevant; home measurements if available] (Include pertinent negatives only when they meaningfully narrow the differential.)

[Problem 2]: [Brief problem label]

(Include only if addressed.) [Status since last visit; key symptoms; treatment response; adherence/barriers; home measurements]

Review of Systems: [Pertinent positives and negatives beyond what is captured above] (Include only if it adds clinical value. If collected via intake questionnaire, note it was reviewed.)

Medications: [Medication list reviewed and reconciled / Medication list could not be fully verified due to [reason]; mitigation: [steps taken]]. [Adherence and side effects reported.]

Allergies: [Allergen] — [Reaction type] (If uncertain, document uncertainty and mitigation.)

Relevant History Updates: [PMH/PSH/FH/SH changes affecting today's decisions] (Include only if relevant to today's visit.)

Objective

Vitals: [Vital signs and values obtained today] (List only vitals actually measured.)

Exam:

• [System examined]: [Pertinent normal and abnormal findings]
• [Additional systems as relevant]

(For telehealth, note exam limitations and video observations.)

Data Reviewed:

• [Point-of-care results with date]
• [Recent labs/imaging with source, date, and key values]
• [External records reviewed with source and date]

Assessment & Plan

(Combine assessment and plan by problem. Number by clinical priority: acute/high-risk first, then chronic, then preventive. Include differential with reasoning when diagnosis is uncertain.)

1. [Problem name]: [new / established]; [improving / stable / worsening / controlled / uncontrolled]

Assessment: [Brief synthesis linking subjective, exam, and data findings; differential if uncertain]

• Diagnostics: [Tests ordered with rationale]
• Medications: [Start / stop / continue / adjust] [medication] [dose] [route] [frequency] [duration]; [safety monitoring if applicable]
• Non-pharmacologic: [Self-care, lifestyle, home monitoring recommendations]
• Counseling: [Key points discussed; patient preferences and response] (Include for preference-sensitive decisions.)
• Referrals: [Referral type] — [Reason and urgency]
• Follow-up: [Timing and modality]; Return precautions: [Symptoms or thresholds prompting earlier contact]

2. [Problem name]: [new / established]; [improving / stable / worsening / controlled / uncontrolled]

(Include additional problems only if addressed.)

Assessment: [Brief synthesis; differential if applicable]

• Diagnostics: [Orders and rationale]
• Medications: [Changes with full details and safety monitoring]
• Non-pharmacologic: [Recommendations]
• Counseling: [If applicable]
• Referrals: [If applicable]
• Follow-up: [Timing]; Return precautions: [If applicable]

Preventive Care

(Include only if addressed today.)

• Screenings/Immunizations: [What was done today; what is due and when]
• Counseling: [Topics discussed and patient response]
• Follow-up: [Timing for next preventive items]

(Omit any sections or bullet points not relevant to this visit. Use patient-friendly language; avoid unexplained acronyms. If key information is unavailable, document the gap and mitigation steps.)