SOAP NOTE TEMPLATE
Review the Rubric for more Guidance
Demographics
Chief Complaint (Reason for seeking health care)
History of Present Illness (HPI)
Allergies
Review of Systems (ROS) General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Vital Signs
Labs
Medications
Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance/ Screenings
Physical Examination General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Diagnosis
Differential Diagnosis
ICD 10 Coding
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Prescription See Below (scroll down)
References
Grammar
EA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature:____________________________________________________________
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
