SOAP Note Template

SOAP Note Template

SUBJECTIVE DATA:

Patient Initials: _____    Age: _____      Gender: _­­­­__

Chief Complaint (CC):

History of Present Illness (HPI):

O
nset:

L
ocation:

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D
uration:

C
haracteristics:

A
ggravating factors:

R
elieving factors:

T
reatments/Therapies:

S
everity:

Medications:

           

Allergies:

SOAP Note Template

Past Medical History (PMH):

            

Past Surgical History (PSH):

 

OB/GYN History:

            Menstrual History:

Age at menarche –

LMP-

Menstrual Pattern

Duration of flow-

Amount of flow-

Associated pain with menses-

Intermenstrual bleeding-

Menopause-

Contraception:

Current method and satisfaction-

Previous methods, complications, and reasons for discontinuation- SOAP Note Template

 

Cervical and vaginal cytology:

Most recent Pap –

History of abnormal pap smears-

Infections:

No history of STIs, vaginitis, or PID (if this is true for your patient)

Fertility/infertility:

      
1.

Sexual History: (example)

Heterosexual, mutually monogamous relationship

No concerns with libido or orgasm. Has experienced intermittent dyspareunia x 1 month.

No history of sexual abuse or assault

Denies sexual intercourse in the last 7 days. SOAP Note Template.

Obstetric history: (example)

G1P1001

Denies maternal, fetal, or neonatal complications

Personal/Social History:

 

Health Maintenance:

(include things such as vitamin supplementation, diet, exercise routine, seatbelt use sunscreen use, firearms in the household, last pap and results, sigmoidoscopy/colonoscopy, bone densitometry, lipid analysis, glucose, or thyroid testing) SOAP Note Template

Immunizations History:

 

Significant Family History:

(don’t forget to list any family history of breast, ovarian, or uterine cancer)

Review of Symptoms:

General:

Skin:

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Hematologic:

Endocrine:

Allergic/Immunologic:

 

OBJECTIVE DATA:

Physical Exam:

Vital Signs

 

General:

HEENT:

Neck:

Chest:

Lungs:

Heart:

Peripheral Vascular:

Abdomen:

Genital/Rectal:

External Genitalia:

Vulva/Labia Majora:

Bartholin Gland:

Skenes:

Clitoris:

Urethra:

Bladder:

Vagina:

Cervix:

Uterus:

Adnexa:

Rectum:

Musculoskeletal:

Neurological:

Lymph Nodes:

Skin:

Lab/Diagnostic Tests and Results
: (example)

Urine hCG- negative

Pap smear- results pending

Vaginal culture- pending

Urine STD panel- pending

Transvaginal US- pending

SOAP Note Template

 

ASSESSMENT:

Differential Diagnosis (DDx):

 Final Diagnosis:

PLAN:

Referrals-

Further labwork or diagnostics needed??

F/U

Health Promotion:

Disease Prevention:

 

Reflection:

            

References

SOAP Note Template