Free Blank Soap Note Template

Blank Soap Note

Prepared by: [Your Name]

Date: ___________________

Patient Name: ______________________

DOB: ______________________

Medical Record Number: ______________________

I. Subjective

The patient's reported symptoms, concerns, and history

  • Chief Complaint (CC): ______________________________

  • History of Present Illness (HPI): ______________________________

  • Review of Systems (ROS): ______________________________

  • Past Medical History (PMH): ______________________________

  • Medications: ______________________________

  • Allergies: ______________________________

  • Social History (e.g., smoking, alcohol use): ______________________________

  • Family History: ______________________________

II. Objective

Clinician’s findings, including observations, vital signs, and examination results

  1. Vital Signs:

    • Temperature: __________

    • Pulse: __________

    • Blood Pressure: __________

    • Respiratory Rate: __________

    • Oxygen Saturation: __________

  2. Physical Exam:

    • General Appearance: ______________________________

    • HEENT (Head, Eyes, Ears, Nose, Throat): ______________________________

    • Cardiovascular: ______________________________

    • Respiratory: ______________________________

    • Abdominal: ______________________________

    • Musculoskeletal: ______________________________

    • Neurological: ______________________________

  3. Laboratory/Diagnostic Results: ______________________________

  4. Imaging: ______________________________

III. Assessment

Clinician’s interpretation based on subjective and objective data

  • Diagnosis/Clinical Impression: ______________________________

  • Differential Diagnosis: ______________________________

  • Severity: ______________________________

IV. Plan

Plan of action for further management

  • Treatment: ______________________________

  • Medications: ______________________________

  • Tests/Labs: ______________________________

  • Referrals: ______________________________

  • Follow-up: ______________________________

  • Patient Education: ______________________________

Name of Clinician: ______________________
Title: ______________________

Note Templates @ Template.net