SOAP (Multiple Issues)

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>
(Include relevant history and associated information in chronological order)
1) [Chief complaint 1]
- [Hyphenated list of symptoms and related history]

2) [Chief complaint 2]
- [Hyphenated list of symptoms and related history]

[etc...]

<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 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 & Plan:</b>
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate. Each assessment and plan number should correlate directly with the subjective section)

1) [Diagnosis 1 and rationale if mentioned]
- [Hyphenated plan]

2) [Diagnosis 2 and rationale if mentioned]
- [Hyphenated plan]

- [Follow up plan]
- [Return precautions]

[etc…]