Zulfiqar Rana, MD, MPH, FACP

How to present a SOAP note for outpatient and general medical and surgical ward (excluding ICU):

Subjective:

Patient complaints usually are in their own words.

OPQRST: Onset, Provocation, Quality, Radiation, Severity, and Timing.

Pertinent ROS

Pertinent Social History

Pertinent Medicines (if needed)

Objective:

Vitals

Pertinent Physical exam:

• Vitals
• HEENT
• Neck
• Respiratory
• CVS
• Abdomen
• Extremities
• Neuro
• Skin
• Others

Labs

Imaging

Assessment:

#1 Complaint:

• Summary of Subjective and Objective briefly usually in one sentence.
• Differential diagnosis
• Most likely diagnosis

#2 Complaint

#3 Complaint

Plan:

• Diagnostics
• Treatment plan
• Ancillary
  • Consults
  • Allied health includes but is not limited to PT, OT, SS, etc.
  • Social issues
  • Disposition
  • Expected length of stay (inpatient only)