Podiatry SOAP Note

Date: [Date]

Patient: [Patient name and identifier]

Provider: [Provider name, credentials]

Visit Type: [new / established] [Follow-up interval if applicable]

Subjective

Chief Complaint: [Primary foot/ankle concern with laterality] (One concise line; include brief patient quote only if provided.)

HPI: [Onset/duration; anatomic location with laterality; quality and severity; timing pattern; aggravating and relieving factors; prior treatments tried and response; functional impact] (Include red flags only if explicitly present: fever, drainage, spreading erythema, acute neurovascular change, inability to bear weight. For diabetic foot risk visits, include history of numbness/burning, prior ulcers or amputations, or vascular procedures if mentioned.)

Pertinent History: [Conditions affecting risk, healing, or treatment] [Podiatry-relevant medications] [Allergies with reaction types] (If medications or allergies were not reviewed, state the reason.)

Objective

General: [Appearance, distress level, gait observation, vitals if relevant] (If expected vitals were not obtained, state reason.)

Lower Extremity Exam: [Vascular findings — pulses, perfusion, edema] [Neurologic findings — sensation, monofilament if diabetic] [Dermatologic findings — skin integrity, nail condition, lesions] [Musculoskeletal findings — tenderness, ROM, deformity, special tests as applicable] (Document only what was examined with laterality throughout. Do not auto-populate normal findings.)

Wound/Ulcer: [Location with laterality, dimensions, depth, base tissue, exudate, periwound changes, infection signs, probe to bone result] (Include only if wound or ulcer present.)

Data: [Imaging, labs, or vascular studies reviewed or obtained with dates] (If providing independent interpretation, label distinctly from radiology reports.)

Assessment

(Number problems by clinical importance. Include laterality, anatomic specificity, brief supporting rationale, severity, and relevant comorbidities. Add differential diagnosis when presentation is not definitive.)

1. [Diagnosis with laterality] — [Clinical rationale; severity; complicating factors; differential if applicable]
2. [Additional problem if present] — [Clinical rationale; severity; complicating factors]

Plan

(Mirror Assessment numbering. For each problem, address treatment, diagnostics, referrals, education, and follow-up as applicable. Omit categories not relevant to the problem.)

1. [Problem name]: [Treatment — conservative care, medications with dosing, footwear/offloading] [Diagnostics ordered] [Referrals] [Patient education] [Follow-up timeframe and return precautions]
2. [Problem name]: [Treatment plan elements as applicable]

Procedure: [Procedure name with laterality and site] — [Indication; consent; anesthesia; technique; findings; post-procedure instructions; specimen disposition if applicable] (Include only if procedure performed. If billing separate E/M same day, state that E/M was significant and separately identifiable.)

(For routine foot care when Medicare coverage depends on systemic disease exceptions, document the qualifying systemic condition, vascular or neurologic findings establishing risk, and that the condition is under active medical management.)