Free Objective Soap Note Design Template
Objective Soap Note Design
Prepared by: [Your Name]
I. Vital Signs
|
Vital Sign |
Measurement |
Notes |
|---|---|---|
|
Heart Rate |
78 beats per minute |
Regular |
|
Blood Pressure |
120/80 mmHg |
Normal |
|
Respiratory Rate |
16 breaths per minute |
Unlabored |
|
Temperature |
98.6°F |
Normal |
II. Physical Exam Findings
|
Category |
Findings |
|---|---|
|
General Appearance |
Well-groomed, no signs of distress |
|
Cardiovascular |
Regular heart rhythm, no murmurs or gallops |
|
Respiratory |
Clear lung sounds, no wheezing or crackles |
|
Abdomen |
Soft, non-tender, no masses or organomegaly |
|
Musculoskeletal |
Full range of motion in all joints, no swelling or deformity |
|
Neurological |
Alert and oriented x3, no focal deficits |
III. Laboratory Results
|
Test |
Result |
Normal Range |
|---|---|---|
|
Complete Blood Count (CBC) |
||
|
Hemoglobin |
14 g/dL |
12–16 g/dL (female), 14–18 g/dL (male) |
|
White Blood Cell Count |
6,000/mm³ |
4,000–11,000/mm³ |
|
Platelets |
250,000/mm³ |
150,000–450,000/mm³ |
|
Test |
Result |
Normal Range |
|---|---|---|
|
Basic Metabolic Panel (BMP) |
||
|
Sodium |
140 mEq/L |
135–145 mEq/L |
|
Potassium |
4.2 mEq/L |
3.5–5.0 mEq/L |
|
Creatinine |
1.0 mg/dL |
0.6–1.2 mg/dL |
|
Glucose |
90 mg/dL |
70–100 mg/dL (fasting) |
|
Test |
Result |
Normal Range |
|---|---|---|
|
Liver Function Tests |
||
|
AST (Aspartate Aminotransferase) |
22 U/L |
10–40 U/L |
|
ALT (Alanine Aminotransferase) |
24 U/L |
7–56 U/L |
|
Bilirubin |
0.8 mg/dL |
0.1–1.2 mg/dL |
IV. Diagnostic Tests
-
Chest X-ray: No acute pulmonary disease, clear lung fields
-
Electrocardiogram (EKG): Normal sinus rhythm, no ST elevation or depression
