Plastic Surgery Clinic SOAP Note

Date/Time: [Date and time of encounter]

Visit Type: [new consult / established / postop follow-up] | [cosmetic / reconstructive]

Provider: [Provider name and credentials]

Referring Provider: [Referring clinician] (Only include if applicable)

Subjective

CC / Goals: [Single-line reason for visit and patient goals] (For aesthetic visits, include a brief patient-quoted goal when helpful. For postoperative visits, include postoperative timeframe and primary concern.)

HPI: [Narrative history of present illness] (For new consults: onset/course, prior procedures, patient priorities and constraints. For follow-ups: lead with interval changes. Include risk-relevant history inline—nicotine status, anticoagulants, wound healing history, surgical candidacy factors. Note source if obtained from someone other than patient. Include pertinent negatives only if clinically meaningful and asked.)

Pertinent History: [Relevant PMH, PSH, high-risk medications, allergies with reactions, social history] (Emphasize prior plastic surgeries, radiation, implants; quantify nicotine. Only include if relevant and not already documented above. Omit this field entirely if nothing additional is pertinent.)

Objective

General: [Brief overall appearance and relevant systemic observations]

Focused Exam: [Findings organized by anatomical region] (Document only what was examined. Include relevant features such as skin quality, symmetry, laxity, masses, sensation, vascular status. Use explicit laterality. Do not auto-populate normal findings not actually observed.)

Measurements: [Standardized measurements in cm with laterality] (Maintain consistent format across visits. Example: "Breast measurements standing: R SN–N 24 cm, L SN–N 25 cm; R N–IMF 8 cm, L 7 cm; BW R 13 cm / L 13.5 cm")

Wounds/Scars: [Location, dimensions, tissue quality, drainage, surrounding skin] (Include only if applicable. For postop: note incision healing, complications, device/implant status.)

Data Reviewed: [Imaging, pathology, outside records, or photos reviewed with dates and brief impression] (Include how interpretation influenced decisions if independently reviewed. Omit if none.)

Clinical Photography: [Views photographed, storage location, consent status] (Note if separate external use authorization obtained. Include chaperone if applicable per policy. Include only if photos were taken.)

Assessment

(Numbered problem list ordered by: medical urgency/safety, functional impact/medical necessity, then aesthetic goals.)

1. [Problem 1]: [Working diagnosis] | [new / chronic / postop day __] | [stable / worsening / improving] — [Key supporting findings]
2. [Problem 2]: [Working diagnosis and status] — [Key supporting findings]
3. [Surgical candidacy]: [Modifiable risks and optimization needs] (Include only if relevant—e.g., nicotine cessation, BMI optimization, radiation history.)

Plan

(Mirror Assessment problem list. For each problem: recommended approach with rationale, options discussed, tailored risks/benefits/alternatives, patient understanding and decision, orders/coordination needed.)

1. [Problem 1]: [Management plan and shared decision-making summary]
2. [Problem 2]: [Management plan]
3. [Risk modification]: [Optimization steps, timelines, referrals] (Only if applicable.)

Consent Discussion: [Diagnosis and natural history, proposed intervention, material risks discussed, alternatives including no treatment, expected recovery, patient questions addressed, patient decision] (Include only if intervention recommended or scheduled. Do not state consent occurred unless it did.)

Follow-Up: [Timing and purpose] (If surgery scheduling, note whether request placed vs. confirmed date.)

Time: [Total minutes and activities] (Include only if billing by time. Example: "42 minutes total including chart review, history/exam, counseling, and documentation.")