Sleep Medicine SOAP Note

Date: [Date of service]

Provider: [Provider name and credentials]

Visit Type: [new patient / established / consultation]

Setting: [in-person / video / telephone]

Subjective

Chief Complaint: [Chief complaint] (One line; may include a brief patient quote.)

History of Present Illness: [HPI narrative] (Begin with the presenting complaint and time course. Include onset, trajectory, symptom severity, functional impact on work, driving, and mood, prior evaluations and treatments with responses, and pertinent comorbidities. Attribute bed partner or witness observations when present. For established patients using PAP, include patient-reported adherence and benefit.)

Sleep History: [Sleep schedule: bedtime, wake time, weekday vs weekend] | [Sleep latency] | [Awakenings] | [Total sleep time] | [Naps] | [Daytime sleepiness vs fatigue, unintentional dozing] | [Drowsy driving episodes or near-misses] | [Caffeine, alcohol, sedating substances with timing] (For established patients, focus on interval changes relevant to the current decision.)

Symptom Review: [Pertinent positives and negatives for working diagnosis] (Include only relevant symptoms. For sleep-disordered breathing: snoring, witnessed apneas, gasping, positional component, nocturia, morning headache. For insomnia: onset vs maintenance pattern, hyperarousal, prior CBT-I or medication trials. For hypersomnia: sleep attacks, cataplexy features, restorative naps, sleep adequacy. For RLS: urge to move at rest with evening predominance. Omit categories not relevant to the current complaint.)

Questionnaires: [Instrument, date, score, interpretation] (e.g., "ESS 01/15/2026: 16/24 - elevated." If not completed, note "[Instrument]: not completed" rather than leaving blank.)

Background: [Relevant PMH, medications, social factors] (Include cardiopulmonary disease, obesity, psychiatric conditions; current medications with timing—especially sedatives, stimulants, opioids; occupation and driving demands. Omit non-pertinent history.)

Objective

Vitals: [BP, HR, SpO2, height, weight, BMI, neck circumference as obtained] (Note if patient-reported.)

Exam: [General appearance and alertness] | [Airway: Mallampati, tonsillar size, nasal patency, retrognathia] | [Cardiopulmonary findings] | [Other pertinent findings] (Use brief targeted statements. Include airway assessment for sleep-disordered breathing concerns. State explicitly if portions not assessed and why.)

Data Reviewed: [Sleep study: type, date, AHI/REI, O2 nadir, severity] | [PAP data: date range, source, settings, usage (mean hours, % nights ≥4h), residual AHI, mask/leak] | [Actigraphy/sleep diary if available] | [Relevant labs with dates] (If data unavailable, state explicitly with reason.)

Assessment

(List problems by clinical priority. Do not document sleep disorders as confirmed without objective testing; use "suspected" or "rule-out" when appropriate.)

[Problem 1]: [Diagnosis] — [confirmed / suspected / rule-out]

[Status: new/established, controlled/uncontrolled, severity] — [Supporting evidence: key symptoms, exam findings, test results]. [Differential diagnosis if not established]. [Safety concerns: drowsy driving risk, safety-sensitive occupation, opioid use, cardiopulmonary comorbidity as applicable].

[Problem 2]: [Diagnosis] — [confirmed / suspected / rule-out]

(Add problems as clinically indicated.)

Plan

[Problem 1]

Testing: [Studies ordered with rationale and pre-test instructions] (Include contingency if negative/inconclusive. Omit if not applicable.)

Treatment: [Therapy details] (For OSA: PAP settings/mask, alternatives considered. For insomnia: CBT-I referral or behavioral interventions—not sleep hygiene alone. For hypersomnia: address insufficient sleep first; document medications with dose/frequency.)

Safety Counseling: [Drowsy driving discussion] (When sleepiness present: document risk discussed, patient's driving status, near-misses, counseling provided, patient verbalized understanding. If not applicable, state "not applicable—patient does not drive.")

Follow-up: [Interval and rationale] (For Medicare PAP patients, note if within 31–91 day compliance window.)

Referrals: [DME, behavioral sleep medicine, dental sleep medicine, ENT, weight management, referring provider communication as indicated]

[Problem 2]

[Plan components as applicable] (Include only relevant components; omit inapplicable sections. When omission could be clinically or legally meaningful, document explicitly.)

Provider Signature: [Name, credentials, date/time]

(Include supervising physician attestation only if required for trainee documentation.)