Neurosurgery SOAP Note

Date/Time: [Date and time of encounter]

Setting: [inpatient / outpatient / ED] — [Specific unit or clinic]

Provider: [Provider name, role, service, attending of record if applicable]

Context: [Postoperative day and procedure, consult reason, or primary diagnosis] (Include only if relevant to today's evaluation.)

Subjective

[Interval changes since last neurosurgery evaluation] (Brief, decision-focused summary of what changed and what matters for today. Include onset/timing, severity, trajectory, and functional impact when explicitly stated.)

• [Neurologic symptoms: headache, seizure, focal weakness, sensory changes, gait instability] (Include only symptoms present; characterize with location, severity, progression.)
• [Spine red flags: bowel/bladder dysfunction, saddle anesthesia, progressive weakness] (State presence or absence if assessed.)
• [Pain characterization and functional impact] (Include if mentioned.)
• [Postoperative or device-related symptoms] (Include only if applicable.)
• [Relevant medication context: anticoagulants, steroids, antiepileptics] (Include only when affecting current decisions.)

Objective

Vitals: [Blood pressure, heart rate, temperature, pain score as relevant] (If not collected, state "not collected" with reason if known.)

Exam: [Neuro exam findings: mental status, cranial nerves, motor, sensory, reflexes, gait/coordination as indicated; wound and device status including incision appearance, drain output, EVD/ICP values, shunt function when applicable] (Document pertinent positives and negatives. Explicitly state any exam limitations with reason.)

Data: [Pertinent labs with values and dates; imaging with modality, date, key findings] (Explicitly state whether images were personally reviewed or radiology report only. If pending or unavailable, state so.)

Assessment

[One-sentence summary: patient identifier, key neurosurgical pathology, current status/trajectory, and most critical supporting data point]

• [Problem 1]: [Working diagnosis] — [stable / improving / worsening]. [Key supporting findings.] (Order problems by clinical severity.)
• [Problem 2]: [Working diagnosis] — [stable / improving / worsening]. [Key supporting findings.]
• [Additional problems as needed]

Plan

1. [Problem title]: [Diagnostics, therapeutics, monitoring parameters, and care coordination as relevant to this problem] (For surgical decisions: include indication, expected benefit, alternatives, timing. For invasive/high-risk interventions: document risk discussion including material risks, benefits, alternatives, patient understanding, and consent status.)

2. [Problem title]: [Plan elements as above]

[Additional problems as needed]

Disposition: [Current disposition/level of care; follow-up interval and responsible service/clinic; explicit escalation criteria such as new weakness, decreased consciousness, wound drainage, or bowel/bladder changes warranting urgent reassessment] (Tailor escalation criteria to patient-specific risks.)

(Do not infer or fabricate findings. If exam components were not performed, state the limitation and reason. If data or imaging are pending or unavailable, state this clearly.)