Internal Medicine SOAP Note

Date of Service: [Encounter date]

Patient: [Name and identifiers]

Provider: [Clinician name and credentials]

Encounter Type: [outpatient follow-up / inpatient progress note / telehealth / other]

Subjective

Chief Complaint: [Reason for today's visit]

[HPI or interval history narrative] (Summarize changes since last visit or overnight events; include symptom trajectory, response to prior plan, medication adherence, new concerns, and pertinent positives/negatives. If history is limited by delirium, language barrier, or other factor, explicitly state the source and limitation.)

Medications: [Summary of changes, adherence issues, or adverse effects] (Include only when there are changes or concerns; omit if no updates.)

Allergies: [Allergen(s) with reaction type / NKDA (verified) / Allergies not reviewed today]

Review of Systems: [Systems reviewed with pertinent findings] (Include only if actually performed; if partial, specify which systems. Omit entirely if ROS was not performed.)

Objective

Vitals: [Relevant vital signs] (If not obtained, document why.)

Exam: [Pertinent physical examination findings by system or problem] (Clearly distinguish normal from abnormal; for telehealth, note modality limitations.)

Data: [Pertinent labs, imaging, and diagnostics reviewed with dates] (Highlight decision-driving values and trends; include your interpretation when it affects management. Do not include pending studies here.)

Assessment

[Age]-year-old [sex/gender] with [key comorbidities], presenting for [encounter context], with [primary clinical issue and current status].

Problem List:

1. [Problem name]: [Status: improving / stable / worsening] — [Working diagnosis or differential with key supporting evidence]
2. [Problem name]: [Status] — [Clinical reasoning]

(List problems in descending order of acuity; include only problems addressed today.)

Plan

1. [Problem 1]: [Diagnostics, therapeutic changes with rationale, monitoring parameters, consults/referrals as relevant]
2. [Problem 2]: [Plan elements as above]

(For each problem, document relevant diagnostics with clinical question, medication changes with dose/route/frequency/duration and rationale, monitoring targets, and consults with reason. Include patient counseling and shared decision-making when it materially affects the plan.)

Follow-up: [Interval and with whom; return precautions tied to condition]

Disposition: [Current plan and barriers to discharge] (Include only for inpatient notes.)

Time: [Total minutes spent] (Include only if using time-based billing.)

Attestation: [Attending attestation statement] (Include only for trainee notes requiring attestation.)

(When information is missing or unobtainable, explicitly state "Unable to obtain due to…", "Not reviewed today", or "Pending" rather than leaving blanks.)