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:

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

 

Cervical and vaginal cytology:

  1. Most recent Pap –
  2. History of abnormal pap smears-

Infections:

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

Fertility/infertility:

      1.

Sexual History: (example)

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

Obstetric history: (example)

  1. G1P1001
  2. 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)

  1. Urine hCG- negative
  2. Pap smear- results pending
  3. Vaginal culture- pending
  4. Urine STD panel- pending
  5. Transvaginal US- pending
  6. SOAP Note Template

 

ASSESSMENT:

Differential Diagnosis (DDx):

 Final Diagnosis:

PLAN:

  1. Referrals-
  2. Further labwork or diagnostics needed??
  3. F/U
  4. Health Promotion:
  5. Disease Prevention:

 

Reflection:

            

References

SOAP Note Template

 

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