SOAP Note – Encounter
SOAP clinical note – S/O/A/P sections
사용법: Clinical encounter documentation. S/O/A/P ordering is standard; de-identify before any export or share.
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SOAP Note – Encounter
Standard clinical documentation format. Template only – not medical advice. De-identify all patient data before storing outside your clinical system.
| Field | Value |
|---|---|
| Date / time | YYYY-MM-DD HH:mm |
| Clinician | Name, role |
| Setting | Clinic / telehealth / ward |
S – Subjective
What the patient reports, in their words where possible:
- Chief complaint: one line
- HPI: onset, duration, character, severity, modifying factors
- History: relevant medical/surgical/family/social history
- Medications: current list
- Allergies: ...
- ROS: pertinent positives/negatives
O – Objective
What you observe and measure:
- Vitals: BP / HR / T / RR / SpO2
- Exam findings: pertinent positives and negatives
- Data: labs, imaging results reviewed
A – Assessment
- Working diagnosis / differential
- Severity, stability
- Clinical reasoning in one or two sentences
P – Plan
- Diagnostics: tests ordered
- Treatment: medications (dose/frequency), procedures
- Education: what was explained to the patient
- Follow-up: when, what to watch for, return precautions
- Referrals: to whom, why
Notes
De-identification reminder: remove name, MRN, DOB, and other identifiers before exporting or sharing this note.