brevaPrimary care SOAP note
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: [ ]