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Adult SOAP Note Template

Class
Your name
Date
Demographics (age, sex)
Source and reliability

S (Subjective):
Chief Complaint(s): Summarize reason for visit, preferably in patient’s own words. Concise (no
more than a few words i.e.: nasal congestion, fatigue, medication refill, etc.).

History of Present Illness

Include OLDCARTS

 Onset and duration of complaint(s) – be specific! Provide accurate and specific

timeframes (ex. Patient reports right shoulder pain for the past 3 days). Never write, the
patient reports right shoulder pain since last Thursday. If the complaint has been ongoing
for months, it is ok to say, “three months or 12 months” since the exact date is unknown.
The key is to ensure no one must look at a calendar when reading the note.
 Location of pain/problem
 Characteristics – radiation, pattern, severity, temporal patterns
 Associated symptoms, Alleviating and aggravating factors
 Relevant pertinent information (ex. How it began, visits to other clinics/hospitals)
 Treatments – medications, interventions (ex. Ice packs, elevation, Tylenol, sinus rinses,
etc.)

Other important subjective information & background:

Allergies: Specific medication and types of reactions

Current Medications: Name and dose of medication, how often they take it, what do they take
it for?
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Pertinent Medical History: Current diagnoses, surgical history, major medical

events/hospitalizations

Preventative History: Mammograms, immunization history, colonoscopy, etc.

Social History: Nicotine, alcohol, and drug use. (Include number of years has the patient been
using the substance, how many times/amounts per day, quitting history). Employment/schooling,
relationship status, children, cultural/ethnic backgrounds

Family History: Include immediate family members only unless organizing a genogram (3
generations back)

Review of Systems
→ ROS questions depend on the HPI/Chief Complaint. This is merely an example broken down
by systems. Add/delete information as needed:

Constitutional: Denies weight change. Denies changes in strength or exercise tolerance. Denies
fatigue. Denies fever or chills. Denies foreign travel. Denies exposure to similar sick contacts.

Neuro: Denies headaches or dizziness. Denies head injury. Denies weakness, tremors, or
seizures. Denies changes in mentation. Denies ataxia. Denies speech disturbances. Denies
paresthesia or numbness.

Eyes: Denies vision changes, scotomata, or diplopia. Denies tearing or redness. Denies eye pain
or pressure. Denies eye drainage or discharge. Denies injury or foreign body.

Ears: Denies changes in hearing or tinnitus. Denies bleeding, discharge, or ear pain. Denies
vertigo.

Nose: Denies epistaxis. Denies coryza or obstruction. Denies discharge. Denies loss of smell.

Throat/Mouth: Denies throat pain. Denies difficulty swallowing. Denies postnasal drip. Denies
dental difficulties. Denies gingival bleeding.

Neck: Denies stiffness or pain. Denies tenderness.

Respiratory: Denies dyspnea. Denies wheezing. Denies cough or hemoptysis.

Cardiovascular: Denies chest pain. Denies palpitations. Denies syncope. Denies orthopnea.
Denies peripheral edema.

GI: Denies changes in appetite. Denies dysphagia. Denies dyspepsia. Denies abdominal pain.
Denies bowel habit changes or melena. Denies nausea or emesis.
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GU: Denies urinary urgency, dysuria, or increased urinary frequency. Denies nighttime voiding.
Denies incontinence. Denies malodorous or bloody urine. Denies changes in the nature of urine.

GYN: Last menstrual period. Denies menstrual irregularities.

Musculoskeletal: Denies pain in muscles or joints. Denies limitations of range of motion. Denies
injury.

Skin: Denies rashes, lesions, or skin changes.

Psychiatric: Denies depressive symptoms. Denies anxiety. Denies intrusive thoughts. Denies
changes in sleep habits. Denies changes in thought content. Denies increased stress.

O: Objective
 Vital Signs (BP, Pulse, Respirations, SPO2, Weight, Height, BMI)

 Focused physical exam

o Refer to your school’s preference, but most SOAP notes are broken down by body
systems
o Focus on the body systems relative to the CC, HPI, and ROS. Leave out
information that is irrelevant. For example, if the patient is complaining of a
finger injury after it was smashed in a mouse trap, it is not necessary to do a GU
or GI exam.

 Include Cardiac and respiratory exams in every SOAP note. It is always a good idea to
listen to heart and lung sounds and chart them for every patient.

 Include results for diagnostic tests conducted in the clinic. Example: Point of care testing
(rapid flu, urinalysis, urine HCG, strep swabs, etc.), x-ray films, EKG, etc. Be mindful
that some schools want this under assessment, so clarify with your professor/clinical
instructor.

For objective examples, each system is listed below with normal findings only. Change the
normal to abnormal when necessary. Again, you may add or deduct as needed. Some systems
will not be part of the focused assessment, but all are included below for reference. Always refer
to your school’s guidelines.

General Physical Exam: Normotensive, in no acute distress.

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Neuro: Alert and oriented. Cranial nerves 2-12 intact. Sensation to pain, touch, and
proprioception intact. DTR’s 2+ in upper and lower extremities. No pathologic reflexes.

HEENT:
Head: Normocephalic, no lesions. No visible or palpable masses, depressions, or scarring.
Eyes: PERRL or PERRLA, EOM intact, conjunctiva clear. Sclera non-icteric, EOM intact. No
exudates, hemorrhages, or drainage.
Ears: EAC's clear, TM's translucent and mobile with no cone of light displacement.
Nose: Mucosa pink and non-inflamed. Turbinates non-edematous. No septal deviation. No
obstruction.
Throat: no exudates, no lesions. Uvula midline. No tonsillar hypertrophy. Mouth: Moist mucous
membranes. No dental caries. No missing teeth.

Neck: Supple. No masses or thyromegaly. No bruits.

Respiratory: Lungs clear to auscultation in all lobes. Chest rise and fall symmetrical. No rales or
wheezes.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. No thrills. Capillary
refill less than 3 seconds. Radial pulses 2+ bilaterally (can include peripheral pulses here). No
varicosities.

Abdomen: Soft, no tenderness, no masses, bowel sounds normal.

Genitourinary: male - Penis circumcised without lesions, urethral meatus patient without
discharge. Testes non-edematous and without palpable masses, scrotum without lesions.

Pelvic: female - Urethral meatus patent. Vagina and cervix without lesions or discharge. Uterus
and adnexa nontender without possible masses.

Rectal: Normal sphincter tone, no hemorrhoids, or palpable masses (can include prostate here if
assessed - prostate firm, no bogginess or nodules).

Back: Normal curvature, no tenderness. No CVA tenderness.

Musculoskeletal: Steady gait. No misalignment, asymmetry or crepitation. No defects,

tenderness, or palpable masses. No instability or atrophy (this can be combined with extremities,
depending on school criteria).

Extremities: FROM. No amputations or deformities. No edema or erythema. Strength and tone

5/5 throughout.

Skin: Good turgor. Skin warm to touch. No rashes or lesions. No ecchymosis, petechiae, or
discoloration (some providers/schools write “skin color consistent with ethnicity” – depends on
preference).
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A: Assessment
 Acute problems always need 3-5 differential diagnoses
 Focus on chief complaint and ROS/focused assessment to develop the differential
 Depending on your school’s requirements, differential diagnoses are typically not needed
for wellness visits or chronic visits for established patients (Ex. hypertension medication
refill, depression medication refill, routine breast cancer screenings, etc)
 When listing the differential, use the ICD-10 codes and place in order of acuity
o Learning ICD codes will benefit you greatly when you begin working.

P: Plan
 List out treatment plan
 Include ordered medications, diagnostic testing, labs, referrals to specialists
 Education and counseling to patient (med side effects, ordered tests, lifestyle mods, etc.).
 Education and counseling to patient regarding specific signs and symptoms to monitor for
and notify provider, signs the current therapy or medication may not be working, things
that may indicate failure of therapy, directions for the patient in case symptoms worsen
 Counsel to patient regarding follow-up and time frame (Ex: number of days the patient
should wait before following up)

Take Note:
 This SOAP note is merely an example to serve as a guideline for writing your notes.
 Each school has a different set of criteria to follow. Always adhere to that or your grades
will certainly suffer.
 Some schools allow the term normal, some do not.
 For abnormal examples, see other templates based on a variety of acute or chronic
illnesses.
 Please do not copy this and give it to your friends. Time and effort were put into this
template to help students navigate graduate school. Feel free to send them to my Etsy
shop. Costs are low and affordable for all.
 As always, please message me if you have any questions or suggestions.