Rheumatology SOAP Note

Date: [Encounter date]

Patient: [Full name] | [Age] | [Sex]

Provider: [Clinician name, credentials]

Primary Rheumatologic Diagnosis: [Primary diagnosis with key context (e.g., serostatus, onset year)]

Chief Complaint

[Reason for visit in one line; use patient's own words when available]

Subjective

[Interval history since last visit: symptom trajectory [improved / stable / worsened / flaring]; current inflammatory features (pain pattern, morning stiffness duration, swelling, fatigue); joint distribution; functional status and impact on daily activities.] (Summarize in a single coherent paragraph.)

Current DMARD/biologic regimen: [Medication(s) with dose/route/frequency] — Adherence: [description including missed doses]; Tolerance: [side effects]; Infections: [intercurrent infections since last visit]. (If adherence or tolerance not assessed, briefly state why.)

[Extra-articular or systemic symptoms relevant to rheumatic disease or therapy] (Include only when present and clinically relevant; omit if none.)

[Pertinent Review of Systems related to today's problems or immunosuppression monitoring] (Include only if performed and relevant; omit entirely if ROS not performed.)

Objective

Vitals: [Relevant measurements with units]

Exam: [General appearance]; [Pertinent findings from systems relevant to today's visit or systemic disease activity] (Include only relevant positives and negatives.)

MSK: [Joint count method: 28 / 66/68], TJC [#], SJC [#]; [Key active joints with laterality]; [Pattern descriptors: synovitis / effusion / ROM limitations / enthesitis / dactylitis as applicable]

Data: [Pertinent labs with dates and trends (inflammatory markers, DMARD monitoring labs)]; [Imaging reviewed with modality, date, and key findings]; [DMARD/biologic monitoring status: last labs with date, results, next due] (State explicitly when expected data are unavailable.)

Assessment

(List only problems addressed today.)

1. [Problem name]: [Diagnosis] — [active / stable / remission / flare], [mild / moderate / severe]. [Supporting evidence from today's subjective and objective findings.] [Disease activity score if used: [CDAI / DAS28 / RAPID3 / BASDAI / ASDAS-CRP]: [value] — [interpretation].] (Include differential diagnosis only if diagnostic uncertainty exists.)
2. [Problem name]: [Diagnosis] — [disease state], [severity]. [Supporting evidence.] [Disease activity score if used.]
3. (Add additional problems as needed.)

Plan

(Organize by problem number to mirror Assessment.)

1. [Problem 1]: [Therapeutic decisions: medication continuation/change/initiation with rationale]; [Monitoring: labs ordered, next due dates]; [Counseling if applicable: infection precautions, vaccines, teratogenicity]; [Referrals if placed]. (For DMARD/biologic initiation or change: include indication, dose/route/frequency, and safety screening status with dates for TB/hepatitis.)
2. [Problem 2]: [Therapeutic decisions]; [Monitoring]; [Counseling if applicable]; [Referrals if placed].
3. (Add additional problems as needed.)

Follow-up: [Timeframe based on disease activity and monitoring needs]

E/M Support

MDM-based: Problem complexity: [low / moderate / high]; Data reviewed: [labs / imaging / external records / discussion with other clinician]; Risk: [medication management / immunosuppression / severe exacerbation risk]

— or —

Time-based: Total clinician time on date of encounter: [minutes] (Include pre-visit review, history/exam, counseling, ordering/reviewing tests, documentation, care coordination.)

Signature: [Clinician name, credentials] — [Date/time signed]