Gastroenterology Clinic SOAP Note

Date/Time: [Date and time of encounter]

Visit Type: [New / Follow-up / Post-procedure]

Clinician: [Clinician name, credentials]

Referring Provider: [Referring provider name and specialty] (Include only for consults; omit otherwise.)

Subjective

Chief Complaint: [Reason for visit or referral question in one line]

HPI: [Concise narrative] (Use 1–2 paragraphs. For new patients, open with patient identifiers and "presents for evaluation of..." then document symptom timeline, severity, functional impact, aggravating/alleviating factors, prior evaluations and treatments with response, and presence or absence of GI alarm features if elicited. For follow-up visits, open with "returns for follow-up of [condition] since [last visit date]" and emphasize interval changes, therapy response, and new symptoms. Clearly label information sources when not from direct patient report, such as "per referral note" or "per outside records." If history is limited, state why.)

Pertinent History:

• [GI procedures and key findings] (Include prior endoscopies, GI surgeries, and relevant pathology with dates. Include only if relevant to today's decisions.)
• [Pertinent medical/surgical history impacting GI care] (e.g., anticoagulation, CKD, cardiopulmonary disease, immunosuppression. Include only if relevant.)
• [Relevant family history] (e.g., colorectal cancer, IBD, liver disease. Include only if it informs today's decisions.)

Medications: [Current GI-related medications with doses and adherence notes; highlight medications affecting GI management] (State whether medication reconciliation was completed or why not possible.)

Allergies: [Allergen list with reaction types / No known allergies / Unable to verify today] (Safety-critical field; always include an explicit statement.)

ROS: [GI review of systems plus clinically relevant extra-GI systems] (Include only if additional to HPI; document pertinent negatives only when meaningful to risk stratification; omit section entirely if not needed.)

Objective

Vitals: [BP, HR, RR, Temp, SpO2, Weight, BMI as relevant] (Include weight and BMI when relevant to the condition. For telehealth, state "Vitals not available.")

Exam: [GI-focused physical examination findings] (Document only elements actually examined. Include general appearance, abdominal exam with localization of any tenderness, and condition-specific findings such as liver stigmata or perianal exam when performed.)

Data Reviewed: [Dated summaries of pertinent labs, imaging, endoscopy reports, and pathology] (Note source if from outside records and whether independently interpreted. Distinguish results reviewed today from tests ordered today.)

Assessment

[One-sentence clinical summary synthesizing the key presentation]

Problem 1: [Diagnosis or problem name] — [Status: new/chronic, controlled/uncontrolled, flare/remission, compensated/decompensated as applicable]. [Brief supporting evidence]. [Differential diagnosis with rationale if uncertain; omit if established and stable.]

Problem 2: [Diagnosis or problem name] — [Status and supporting evidence as above]

(List additional problems in order of acuity/priority using the same structure.)

Plan

Problem 1: [Diagnostics ordered with rationale and conditional next steps; treatment changes with dose/frequency/duration; dietary or lifestyle counseling discussed; monitoring schedule and red flags; follow-up timing and communication plan] (When recommending endoscopy, document indication, anticoagulation management, sedation concerns, and whether informed consent was discussed. When starting high-risk medications or patient declines workup, document shared decision-making.)

Problem 2: [Diagnostics, treatment, monitoring, and follow-up as relevant]

(Continue for additional problems.)

Return Precautions: [Warning signs warranting urgent evaluation] (Include when clinically appropriate, e.g., GI bleeding, food impaction, severe pain, fever with immunosuppression, confusion in cirrhosis.)

(If billing by time) Total clinician time on [date]: [X] minutes.