SOAP with ROS

Template structure

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

Subjective:
(hyphenated list)
- [Chief complaint or reason for visit]
- [History of present illness: relevant history and associated information in chronological order]
- [Pertinent past medical history]

Review of Systems:
(hyphenated list)
- [General: Fever, chills, weight loss, fatigue, etc.]
- [Skin: Rash, itching, lesions, etc.]
- [Head/Eyes/Ears/Nose/Throat: Headache, vision changes, hearing loss, sore throat, etc.]
- [Cardiovascular: Chest pain, palpitations, edema, etc.]
- [Respiratory: Cough, shortness of breath, wheezing, etc.]
- [Gastrointestinal: Nausea, vomiting, diarrhea, constipation, abdominal pain, etc.]
- [Genitourinary: Dysuria, frequency, hematuria, incontinence, etc.]
- [Musculoskeletal: Joint pain, muscle aches, back pain, etc.]
- [Neurological: Dizziness, weakness, numbness, seizures, etc.]
- [Psychiatric: Depression, anxiety, sleep disturbances, etc.]
- [Endocrine: Polyuria, polydipsia, heat/cold intolerance, etc.]
- [Hematologic/Lymphatic: Easy bruising, bleeding, lymphadenopathy, etc.]
- [Allergic/Immunologic: Allergies, frequent infections, etc.]

Objective:
(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] (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)

Assessment:
(hyphenated list)
- [Diagnosis and reasoning] (Use medical terminology if appropriate. Do not re-state all past medical history unless relevant)
- [Differential diagnosis if mentioned]

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