General Practice SOAP Note

Estrutura do template

Esta é a estrutura que o Notat segue quando escreve a nota da consulta — nunca a preenche à mão.

Subjective:
(hyphenated list)
- [Chief complaint or reason for visit]
- [History of present illness: onset, duration, progression, associated symptoms]
- [Relevant past medical history]
- [Medication history]
- [Allergies]
- [Family history]
- [Social history: tobacco, alcohol, recreational substances, occupation, living situation]
- [Review of systems: pertinent positives and negatives]

Objective:
(hyphenated list)
- [Vital signs: HR, BP, T, RR, O2 sats]
- [General appearance]
- [Physical exam findings by system: e.g., HEENT, Cardiovascular, Respiratory, Abdomen, Musculoskeletal, Neurological, Skin]
- [Relevant investigation results]

Assessment:
(hyphenated list)
- [Primary diagnosis or clinical impression]
- [Differential diagnosis if applicable]
- [Relevant reasoning or supporting findings]

Plan:
(hyphenated list)
- [Investigations ordered or planned]
- [Medications prescribed or adjusted]
- [Non-pharmacological management]
- [Patient education and counselling]
- [Referrals to specialists or allied health]
- [Follow up plan]
- [Return precautions]