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Primary Care Physician
25-30 minutes

Subjective, Objective, Assessment, Plan

This S.O.A.P. note template from s10.ai is crafted specifically for General Practitioners to meticulously document patient encounters. It encompasses subjective complaints, objective findings, assessments, and treatment plans, making it perfect for monitoring patient progress and managing treatment strategies. This template is especially beneficial for recording complex cases, such as asthma exacerbations and associated symptoms. By integrating this template with s10.ai, healthcare providers can effectively capture comprehensive patient data, ensuring detailed and systematic medical records. Ideal for those seeking 'general practitioner SOAP note examples' or 'medical documentation examples', this template encourages clinicians to explore and implement a more organized approach to patient care.

4,129 uses
4.8/5.0
D
David L
Template Structure

Organized sections for comprehensive clinical documentation

SUBJECTIVE:
• Chief Complaint:
[Primary symptom(s) reported by the patient.]
• History of Present Illness:
[Detailed description of symptom onset, duration, characteristics, aggravating and relieving factors, prior episodes, treatments tried, and impact on daily activities.]
• Associated Symptoms:
[List any additional symptoms reported.]
PAST MEDICAL HISTORY:
• [Relevant medical diagnoses.]
• [Past surgeries.]
• [Immunization status.]
• [Relevant prior investigations or treatments.]
SOCIAL HISTORY:
• [Smoking status.]
• [Alcohol or substance use.]
• [Living situation.]
• [Occupation.]
FAMILY HISTORY:
• [Relevant hereditary conditions.]
OBJECTIVE:
• General:
[Overall appearance (e.g., NAD—No Acute Distress).]
• Vital Signs:
◦ BP: [Value] mmHg
◦ HR: [Value] bpm
◦ Temp: [Value] °C
◦ O2 Saturation: [%]
◦ Weight: [kg]
◦ Height: [cm]
• Respiratory Exam:
[Findings: breath sounds, wheezing, etc.]
• Abdominal Exam:
[Findings: tenderness, distension, organomegaly.]
• Other Systems:
[Include as appropriate.]
ASSESSMENT & PLAN:
Problem 1: [Condition]
• Assessment:
[Brief summary of likely diagnosis.]
• Differential Diagnosis:
◦ [Differential #1]
◦ [Differential #2]
• Investigations Planned:
◦ [List planned tests.]
• Treatment Planned:
◦ [List treatments or prescriptions.]
• Relevant Referrals:
◦ [Referral details.]
Problem 2: [Condition]
• Assessment:
[Brief summary of likely diagnosis.]
• Differential Diagnosis:
◦ [Differential #1]
◦ [Differential #2]
• Investigations Planned:
◦ [List planned tests.]
• Treatment Planned:
◦ [List treatments or prescriptions.]
• Relevant Referrals:
◦ [Referral details.]
Follow-Up:
[Instructions for follow-up appointments or monitoring.]
Sample Clinical Note

Example of completed documentation using this template

S:  
The patient, a 45-year-old male, presents with a primary complaint of a persistent cough and shortness of breath lasting for the past two weeks. The cough is dry and predominantly occurs at night, while the shortness of breath intensifies with physical activity. The patient has attempted using over-the-counter cough syrup with minimal relief. Symptoms have progressively worsened over the past week. He mentions experiencing similar episodes in the past, typically during the winter months, which were managed with inhalers. The symptoms are impacting his ability to perform daily activities, including his work as a construction worker. He also reports fatigue and occasional wheezing.
PMedHx:  
The patient has a history of asthma diagnosed in childhood, with occasional flare-ups. He underwent an appendectomy at age 20. No recent investigations or treatments relevant to the current complaints. Immunizations are current.
SocHx:  
The patient is a non-smoker and consumes alcohol socially. He resides with his wife and two children.
FHx:  
Family history of asthma in the mother.
O:  
NAD  
BP: 120/80 mmHg, HR: 78 bpm, Wt: 85 kg, T: 37°C, O2: 96%, Ht: 180 cm  
Resp: Chest clear, no decreased breath sounds  
No distension, BS+, soft, non-tender to palpation and percussion. No organomegaly
A/P:  
1. Asthma exacerbation  
Assessment: Likely diagnosis is asthma exacerbation  
Differential diagnosis: COPD, bronchitis  
Investigations planned: Spirometry, chest X-ray  
Treatment planned: Prescribe inhaled corticosteroids and bronchodilators  
Relevant referrals: Referral to pulmonologist for further evaluation
2. Fatigue  
Assessment: Likely diagnosis is related to asthma exacerbation  
Differential diagnosis: Anemia, sleep apnea  
Investigations planned: Complete blood count, sleep study  
Treatment planned: Address underlying asthma exacerbation  
Relevant referrals: None at this time
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation by incorporating high-search healthcare and clinical keywords, ensuring thorough and efficient record-keeping. It covers all essential aspects of patient evaluation, including reasons for visit, chief complaints, and detailed symptom analysis, such as duration, severity, and progression. The template also prompts clinicians to document past medical history, social and family history, and any contributing factors, providing a holistic view of the patient's health. Objective findings from physical exams and vital signs are meticulously recorded, ensuring accuracy and clarity. The assessment and plan section allows for precise documentation of diagnoses, differential diagnoses, planned investigations, treatments, and referrals. By adopting this template, healthcare professionals can enhance their clinical workflows, improve patient care, and ensure compliance with medical documentation standards. Explore this template to optimize your practice's efficiency and accuracy in patient management.
Frequently Asked Questions

Common questions about this template and its usage

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Subjective, Objective, Assessment, Plan