# 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

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*De-identification reminder: remove name, MRN, DOB, and other
identifiers before exporting or sharing this note.*