SOAP Note Template

Document patient encounters clearly with structured Subjective, Objective, Assessment, and Plan sections.

Name: ____________________________Course: __________________Date: ____________

Patient & EncounterInitials, age, date, setting. Never include identifying details.

S: SubjectiveChief complaint in the patient's words. HPI using OLDCARTS: onset, location, duration, character, aggravating, relieving, timing, severity.

History, Meds & AllergiesRelevant medical, family, and social history. Current medications and allergies.

Review of SystemsPertinent positives and negatives by system.

O: ObjectiveVitals, focused physical exam findings by system, labs and diagnostics.

A: AssessmentPrimary diagnosis with supporting reasoning. Differentials considered and why they were ruled in or out.

P: PlanDiagnostics ordered, treatment, patient education, referrals, and follow-up.