Student SOAP Note

Encounter Date: [Encounter date]

Time: [Time]

Location/Service: [Location or service line]

Student Author: [Name, role]

Supervising Resident: [Name]

Supervising Attending: [Name]

Data Sources: [Sources and reliability] (List sources such as patient interview, caregiver, chart review, interpreter; note reliability limitations if present.)

Subjective

Chief Concern: [Chief concern] (For inpatients: daily follow-up with symptom focus. For ambulatory: patient-stated reason for visit.)

Interval History: [Interval history] (For inpatients: overnight events, symptom changes, functional status, diet tolerance, patient questions. For ambulatory: changes since last visit, medication adherence, relevant home monitoring, red flags assessed. Qualify source when relevant.)

Pertinent History Updates: [New or changed information] (Include only updates such as allergies, medication reconciliation issues, or social factors affecting care. Omit this field if no updates.)

Objective

Vitals: [Most recent vital signs with timestamp; include oxygen delivery if applicable]

Exam: [Targeted, problem-relevant physical exam findings with pertinent positives and negatives] (State limitations if exam was restricted. Document only findings personally performed.)

Data: [Key labs with trends, imaging impressions, relevant microbiology, I/O if inpatient] (State "No new results" when applicable rather than leaving blank.)

Assessment

Summary: [One to three sentence synthesis: age, key history, clinical context, hospital day if inpatient, current status, and dominant active issues]

Problem List: (Prioritize by acuity. Number problems to align with Plan.)

• [Problem 1]: [Status today, brief supporting data from S/O, differential if diagnosis uncertain]
• [Problem 2]: [Status today] (Add additional problems as needed.)

Plan

(Problem-oriented, numbered to match Assessment. For each problem, include relevant elements: diagnostics, therapeutics with medication details, monitoring parameters, disposition or follow-up. Distinguish "Ordered today" from "Recommend/consider" for items pending supervisor approval.)

• [Problem 1]: [Plan details]
• [Problem 2]: [Plan details]

Signature & Routing

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

Route to: [Supervising resident and/or attending for review]

Feedback requested: [Yes / No]

(Supervising clinician should document attestation separately confirming review, corrections made, and personal involvement per institutional and CMS requirements.)

(Omit fields with no relevant content rather than entering N/A, except where absence could be misread as "normal" or "not assessed"—in those cases state explicitly. Use source qualifiers such as "Per patient," "Per chart," or "Per nursing" when the source matters. Avoid copying large data blocks; emphasize trends and clinically meaningful results.)