SOAP Note Template 3rd Version (shorter)

Subjective:
Date and Time of Exam:
Patient Identification:
- Name:
- DOB/Age:
- Identifies as:
- Preferred pronouns:
- Preferred language:
- Source of Information:
- Reliability:

Chief Complaint:
HPI:
- O (onset):
- L (location):
- D (duration):
- C (character):
- A (associated/aggravating factors):
- R (relieving factors):
- T (treatment):
- S (setting/severity of symptoms):
- Pertinent positives/negatives:
- Risk factors:

PMH/Childhood diseases:
PSH:
Prior hospitalizations:
Family History:
- Father:
- Mother:
- Siblings:
Psychiatric History:
Social History:
- Lives with:
- History of Trauma/Violence:
- Tobacco Use:
- Intends to Quit?:
- Alcohol Use:
- Drug Use:

Health Maintenance:
- Immunizations (childhood/adult):
- Cancer Screenings:
- Injury Prevention:
- Guns in home?:
- Wears seatbelt and helmet?:
- Smoke alarms:
- Occupational/environmental hazards:

Medications:
Allergies:
Review of Systems:
- General (weight loss/gain, fatigue, fever and chills, changes in sleep):
- Skin (rashes, moles, itching/dryness, color change):
- HEENOT (headache, hearing change, vision change, vertigo, congestion, rhinorrhea, sore
throat, sputum, glasses/contacts, gingival bleeding, oral cavity ulcers):
- Breast (any masses/lumps, nipple discharge, pain):
- Respiratory (cough/sputum, hemoptysis, dyspnea, wheezing, pleuritic pain, history of
positive PPD):
- Cardiovascular (palpitations, diaphoresis, orthopnea, edema, claudication, pain, EKG,
stress test):
- Gastrointestinal (nausea/vomiting, diarrhea, constipation, appetite change, bleeding):
- Genitourinary (urinary frequency/urgency, pain, burning, hematuria, nocturia,
incontinence, flank pain, reduced force of stream):
- Reproductive:
 - Male (lump/pain/swelling in scrotum, discharge, sores on penis, erectile dysfunction):
- Female (vaginal pain/discharge/itching/odor/dryness, irregular/changed/missed
periods, sores/lumps, premenstrual symptoms, hot flashes):
- Musculoskeletal (muscle/joint pain, muscle stiffness, back pain, swelling of joints,
fractures):
- Neurologic (dizziness, fainting, seizures, numbness/tingling, tremor, falling):
- Endocrine (hot/cold intolerance, sweating, polyuria, polydipsia, bleeding, flushing):
- Psychiatric (depression, anxiety, memory loss, thoughts of harming self/killing self, feeling
restless)

Objective:
Vital Signs:
- BP:
- HR:
- RR:
- Temp:
- SpO2:
- Height | Weight | BMI:
- Height:
- Weight:
- BMI:

Physical Exam:
- GENERAL:
- HEENOT
- NECK:
- RESPIRATORY:
- CARDIOVASCULAR:
- ABDOMINAL:
- EXTREMITIES:
- NEURO:
- SKIN: