SOAP Note

Subjective

[Chief complaint and History of Present Illness] (Briefly state the primary reason for the visit, clearly describing symptom onset, duration, frequency, severity, location, quality, progression, and context. Include modifiers such as relieving or exacerbating factors, self-treatment attempts, and impact on daily activities if explicitly mentioned. Also include any associated symptoms explicitly stated. Combine these details into a single coherent paragraph.)

[Relevant Past Medical, Social, and Family History] (Briefly summarize any past medical history, lifestyle factors, social determinants, occupational exposures, substance use, or family conditions explicitly relevant to the presenting complaint. Only include if explicitly mentioned.)

Objective

(The Objective section should contain only clinician-observed or measured findings, such as vital signs, physical examination results, and completed test outcomes; patient-reported symptoms or histories belong exclusively in the Subjective section, and clinician assessments and plans belong exclusively in the A&P section. Only output bullet points that have been explicitly mentioned in the transcript. Don't output empty bullet points if there is no relevant content. Don't include the label - e.g. "Vital signs" - only the relevant content.)

• [Vital signs] (Only include if explicitly mentioned)
• [Physical and/or mental examination findings] (Summarize findings by relevant body systems or examination focus, only if explicitly mentioned.)
• [Completed investigations and results] (Do not include investigations that are planned or pending. Only include if explicitly mentioned.)
• [Laboratory, imaging, diagnostic, and any other test results] (Only include completed tests with results explicitly mentioned)
• [Other objective findings] (Include any other current facts as measured or stated by the clinician that don't fit the above categories. Only include if explicitly mentioned. Add additional bullet points as appropriate to group the remaining results naturally.)

Assessment & Plan

(The Assessment & Plan section should clearly summarize the clinician's explicit clinical impressions, diagnoses, differentials (if mentioned), and subsequent management steps; it should not introduce patient-reported information or data not explicitly stated by the clinician.)

[Problem 1]: [Diagnosis or clinical impression] (Clearly state the primary problem or diagnosis explicitly mentioned. Summarize clinician's assessment briefly in one concise paragraph. Include differential diagnoses only if explicitly mentioned. Do not infer diagnoses or include speculative conditions not explicitly stated. Avoid extraneous details or repetition of information already listed in Subjective or Objective sections.)

• [Plan] (Clearly and succinctly outline recommended treatments. Break down the plan into separate bullet points as appropriate, specifying medications with doses and frequencies if mentioned, investigations planned explicitly, patient education or counseling points clearly discussed, referrals explicitly stated, and explicit follow-up actions. Do not include general health advice, pending investigations without explicit mention, or actions not directly tied to the presented problem. Do not include )

[Problem 2]: [Diagnosis or clinical impression] (Include only if additional issues were explicitly discussed.)

• [Plan] (Follow the same detailed guidance provided for Problem 1.)

(Do not infer or include any information not explicitly stated in the transcript. Leave sections blank if information is not available.)