SOAP

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

<b>Subjective:</b>
(hyphenated list)
- [Brief statement of chief complaint or reason for visit]
- [Relevant associated history in chronological order]
- [Past medical history if relevant]
- [Medications if relevant]

<b>Objective:</b>
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings directly examined] (Format as "System: Exam findings", one system per line. Specify anatomical location and laterality if relevant)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>Assessment:</b>
(hyphenated list)
- [Diagnosis and reasoning] (Use medical terminology if appropriate.  Only include active issues being managed during the visit, do not list stable chronic conditions, resolved issues, or past medical history)
- [Differential diagnosis if mentioned]

<b>Plan:</b>
(hyphenated list)
- [Investigations planned or ordered]
- [Treatment plan]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]