PM&R Outpatient New Patient Evaluation (SOAP)

Encounter type: PM&R Outpatient – New Patient Evaluation

Date/Time: [Date and time]

Clinic location: [Clinic location]

Referring clinician and reason for referral: [Referring clinician and referral reason] (Include only if referral-based; otherwise omit)

Primary care clinician: [Primary care clinician]

Historian: [Historian and reliability] (Note if history obtained from patient, caregiver, or chart review; document reliability limitations and interpreter use if applicable)

External records reviewed: [Sources reviewed] (List at high level; detailed review goes in Diagnostic Data Reviewed)

Subjective

Chief Complaint

[Primary symptom or functional complaint] (One concise line capturing top 1–3 concerns with functional context; may include brief patient quote when it clearly conveys the concern)

History of Present Illness

[Narrative of current condition] (Begin with chief complaint context and include onset/duration, mechanism or precipitating event, location/radiation, quality/intensity, aggravating/alleviating factors, diurnal pattern, and sleep impact. For musculoskeletal or neurologic concerns, address neurologic features such as numbness, tingling, weakness, gait instability, and bowel/bladder changes; include targeted red-flag screening as appropriate. Conclude with functional impact on walking/standing/sitting tolerance, stairs, transfers, ADLs, work demands, and recreation. Document patient treatment priorities and goals.)

Functional History

• Prior level of function: [Baseline function before current problem]
• Current function:
  • Mobility: [Bed mobility, transfers, gait distance and device, wheelchair use]
  • Balance and falls: [Fall frequency, injuries, fear of falling]
  • ADLs: [Bathing, dressing, toileting, feeding]
  • IADLs: [Cooking, shopping, driving, medication management]
• Work/school: [Job/school tasks, current restrictions, duty status, ergonomics]
• Home environment: [Stairs, bathroom setup, supports, caregiver assistance]
• Assistive devices/orthoses: [Current equipment, fit, adherence]
• Patient-reported outcome measures: [Measure name, score, date] (Include if obtained)

(If functional assessment is incomplete, state why and plan to obtain missing details.)

Prior Treatments and Response

• Therapy history: [PT/OT/SLP with dates, setting, focus, response, discharge reason]
• Injections/procedures: [Type, site/level, date, benefit duration]
• Related surgeries: [Procedure, date, outcome]
• Medications tried: [Agents, efficacy, adverse effects, reason stopped]
• Non-pharmacologic modalities: [Bracing, activity modification, HEP adherence]

Prior Diagnostics

[Modality, body region, date, key finding] (If report not available, note "requested from [source]")

Past Medical and Surgical History

[Relevant comorbidities and surgeries] (Focus on conditions affecting rehabilitation choices or risk: diabetes, osteoporosis, anticoagulation, immunosuppression, OSA, CKD, mood disorders, substance use disorder, prior neurologic conditions, surgeries affecting biomechanics or neurologic status)

Medications

[Current medications with dose/route/frequency] (Highlight anticoagulants, antiplatelets, opioids, benzodiazepines, muscle relaxants. Document medication list reviewed and reconciled with patient; note adherence issues or access barriers. If unable to confirm, state reason and mitigation plan.)

Allergies

[Substance, reaction type, severity] (Distinguish allergy from intolerance)

Social History

[Living situation, supports, transportation, work status and physical demands, tobacco/alcohol/substance use, exercise and sleep patterns] (Include elements relevant to treatment planning and risk)

Family History

[Relevant familial conditions] (Include only if pertinent to presenting problem such as inflammatory arthritis or neuromuscular disease; otherwise omit this section entirely)

Review of Systems

[Targeted positives and negatives] (Include pertinent findings supporting the differential and safety screening: fevers, weight loss, night pain, bowel/bladder changes, saddle anesthesia, progressive weakness as applicable; avoid exhaustive listing)

Objective

Vitals

[BP, HR, weight/BMI, pain score] (Include orthostatic vitals if indicated)

General Appearance

[Appearance, distress level, affect, communication]

Physical Examination

(Include only elements actually examined. Specify what was examined even when normal.)

• Inspection/posture: [Alignment, asymmetry, atrophy, swelling, skin integrity]
• Palpation: [Tenderness locations, trigger points, warmth, effusion]
• Range of motion: [Active and passive ROM; pain-limited vs mechanically restricted]
• Strength: [Key muscle groups with grading method]
• Sensation: [Dermatomal or peripheral nerve distribution findings]
• Reflexes: [DTRs and pathologic reflexes]
• Tone/spasticity: [Presence and functional impact]
• Special tests: [Provocative maneuvers with interpretation]
• Gait and balance: [Device use, deviations, endurance]
• Functional testing: [Sit-to-stand, transfers, stair simulation]

Diagnostic Data Reviewed

(List items personally reviewed today. Separate reviewed from ordered. Note independent interpretation if performed. Document retrieval plan if data unavailable.)

• Imaging: [Modality, body region, date, source, key findings]
• Electrodiagnostics/labs: [Type, date, key results]
• External notes: [Author, specialty, date, salient points]

Assessment

Summary

[Two to four sentence synthesis integrating patient profile, key symptoms, significant objective findings, working diagnosis with uncertainty level, key functional limitations, and contextual barriers]

Problem List

(Number problems by clinical severity or functional impact. For each problem, include applicable elements below.)

1. [Problem name]: [Working diagnosis] – [acute / subacute / chronic], [stable / progressive / flare]

   • Supporting findings: [Pertinent history, exam, imaging]
   • Differential diagnosis: [Alternative diagnoses] (Include only when uncertainty, atypical features, or red flags present)
   • Functional impact: [Impairments → activity limitations → participation restrictions]
   • Modifying factors: [Comorbidities, psychosocial factors, equipment barriers]
   • Risk stratification: [Falls, neurologic compromise, treatment risks] (Include when relevant)

(Add additional numbered problems as needed following the same structure)

Plan

(Organize by problem. Include only applicable categories for each problem.)

1. [Problem name] – Plan

   • Education and shared decision-making: [Diagnosis explanation, options discussed, risks/benefits, patient preferences, agreed goals]
   • Activity and self-management: [Activity modification, pacing, ergonomics, sleep positioning, home exercise]
   • Medications: [Start/stop/adjust with indication, dose, monitoring, safety counseling] (For high-risk medications, document rationale and risk mitigation)
   • Therapy referral: [PT/OT/SLP, focus areas, precautions, relevant comorbidities, functional goals]
   • Procedures/injections: [Indication, functional target, conservative measures attempted] (If performed today, reference separate procedure note)
   • Diagnostics ordered: [Test ordered, clinical question, how results will change management]
   • Referrals: [Specialty or community resources; communication to referring clinician if applicable]
   • DME/orthoses/prosthetics: [Device, medical necessity in functional terms, training needs]
   • Work/school recommendations: [Restrictions, accommodations, duration, reassessment plan]
   • Follow-up: [Timing, parameters to reassess, return precautions with specific red flags]

(Add additional numbered problem plans as needed following the same structure)

(Same-day procedures: Maintain a separate procedure note including informed consent, verification/time-out, technique, and post-procedure instructions. Document separately identifiable E/M work in the Plan above.)

(Missing information: Document explicitly using "not obtained," "patient unsure," or "records requested." Do not infer items requiring explicit confirmation such as allergies, anticoagulation status, or neurologic red flags.)