SOAP Note Template

• SOAP Note Template

SUBJECTIVE DATA:

Patient Initials: _____    Age: _____      Gender: _­­­­__

Chief Complaint (CC):

History of Present Illness (HPI):

Onset:

Location:

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Duration:

Characteristics:

Aggravating factors:

Relieving factors:

Treatments/Therapies:

Severity:

Medications:

           

Allergies:

SOAP Note Template

Past Medical History (PMH):

            

Past Surgical History (PSH):

 

OB/GYN History:

            Menstrual History:

1. Age at menarche –
2. LMP-
3. Menstrual Pattern
   1. Duration of flow-
   2. Amount of flow-
   3. Associated pain with menses-
   4. Intermenstrual bleeding-
4. Menopause-

Contraception:

5. Current method and satisfaction-
6. Previous methods, complications, and reasons for discontinuation- SOAP Note Template

 

Cervical and vaginal cytology:

7. Most recent Pap –
8. History of abnormal pap smears-

Infections:

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

Fertility/infertility:

      1.

Sexual History: (example)

10. Heterosexual, mutually monogamous relationship
11. No concerns with libido or orgasm. Has experienced intermittent dyspareunia x 1 month.
12. No history of sexual abuse or assault
13. Denies sexual intercourse in the last 7 days. SOAP Note Template.

Obstetric history: (example)

14. G1P1001
15. 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)

16. Urine hCG- negative
17. Pap smear- results pending
18. Vaginal culture- pending
19. Urine STD panel- pending
20. Transvaginal US- pending
21. SOAP Note Template

 

ASSESSMENT:

Differential Diagnosis (DDx):

 Final Diagnosis:

PLAN:

4. Referrals-
5. Further labwork or diagnostics needed??
6. F/U
7. Health Promotion:
8. Disease Prevention:

 

Reflection:

            

References

SOAP Note Template