Universal SOAP Note Template

Subjective:
- Chief Complaint:
- History of Present Illness:
- Review of Systems:
- Medications  Allergies:

Subjective Addenda:
- Social/Family History Updates:
- Patient Goals/Concerns:

Objective:
- Vital Signs:
- Physical Exam Highlights:
- Labs/Imaging Reviewed:
- Point-of-Care Testing:

Assessment:
- Primary Diagnosis:
- Differential Diagnosis:
- Problem List with Status:

Plan:
- Diagnostics Ordered:
- Therapeutics/Medications:
- Patient Education:
- Follow-up  Disposition:

Sign-off:
- Provider Name  Credentials
- Date / Time