Diabetes SOAP Note

Uses a SOAP structure for a diabetes follow-up, including current treatment, blood pressure, A1C, lipid values, and weight. The assessment and plan document control, medication decisions, lifestyle advice, and return timing.

Use for a routine diabetes visit to review current control, measurements, and treatment.

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Completed note example

See how this format reads in practice. The reusable template and supporting clinical facts are below.

Completed note

S: Here today for diabetes follow-up. Reports feeling well overall and no medication changes since the last visit. Denies symptomatic low glucose episodes.

Patient currently taking metformin 500 mg orally twice daily.

O/E
BP: 128/76 mmHg
Please see diabetes flow sheet below.
A1C: 7.6%, increased from 7.2%.
LDL: 92 mg/dL, decreased from 101 mg/dL.
HDL: 48 mg/dL, unchanged from 48 mg/dL.
Wt: 82 kg, increased from 80 kg.

A:
Diabetes under suboptimal control based on A1C trend.
LDL near target; continue monitoring.
Weight up from last appointment.
BP is at target.
Reviewed current medication routine and home glucose monitoring.

P:
Advised to continue a balanced diabetic diet and regular activity as tolerated.
Continue current medication regime; no adjustment made today.
Discussed recording home readings and bringing them to the next visit.
Will see back in three months for a diabetes visit.
Return sooner with persistent high or low readings or other concerns.

Illustrative case with invented patient details. This is not a real patient record or clinical guidance. Review each note against your own consultation.

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Clinical facts behind the note

chief complaint

Routine diabetes follow-up

denials of symptoms

No symptomatic hypoglycemia

medications

Metformin 500 mg twice daily

vital signs

Blood pressure 128/76 mmHg

assessment

A1C 7.6%, increased from 7.2%

LDL 92 mg/dL, decreased from 101 mg/dL

Weight increased by 2 kg

plan

Continue current medication and follow up in three months

Reusable template structure

S: Here today for diabetes visit. No changes in medication since last seen. Over all feels doing well. 

Patient currently taking (add diabetic medication)

O/E
BP:
Please see diabetes flow sheet below 
A1C: [current A1C] increased/decreased from [previous A1C]
LDL: [current LDL] increased/decreased from [previous LDL]
HDL: [current HDL] increased/decreased from [ previous HDL]
Wt: [current wt in kilograms ] increased/decreased from [previous wt in kilograms ]

A:
Diabetes under good/sub optimal control
LDL at target/not at target
Weight up/down from last apt
BP is at/not at target
Discussed insulin regime in detail 


P:
Advised to continue with diabetic diet/exercise etc
I have advised to continue with current medication regime
I have added the following medications to current regime:
I will see back in 3/6 months for diabetic visit 
See sooner with any other concerns

Your consultation. This note format.

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Use this format for your next consultation

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