Primary care SOAP note
United States | Family medicine

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

SUBJECTIVE
Reason for visit: [ ]
Symptoms, onset, course and functional impact: [ ]
Relevant history: [ ]
Medications and allergies reviewed: [ ]
Review of systems actually obtained: [ ]

OBJECTIVE
Vitals measured today, with units: [ ]
Examination performed and findings: [ ]
Tests or records reviewed, with dates and sources: [ ]

ASSESSMENT
Problems addressed today: [ ]
Clinical reasoning and diagnostic uncertainty: [ ]

PLAN
Management for each problem: [ ]
Orders, medication decisions and counseling: [ ]
Shared decisions and patient preferences: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]