01 / ADAPTABLE OUTLINE
What to document
Subjective
Chief complaint; symptom onset, duration, and course; relevant history, medications, allergies, and patient-reported positives and negatives.
Objective
Recorded vital signs, examination findings actually obtained, and available test results. Distinguish patient reports from observed findings.
Assessment
Problem summary, working diagnosis, relevant differential, and reasoning supporting the assessment. Document uncertainty when the cause is not established.
Plan
Tests, treatment, counseling, shared decisions, follow-up interval, and specific return precautions. Separate proposed actions from completed actions.
02 / WORKED EXAMPLE
Follow-up for left knee pain
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Subjective
A 45-year-old patient returns for two weeks of left knee pain after increasing walking distance. Pain is worse on stairs and improves with rest. No fall, fever, locking, or giving way is reported. Medication and allergy lists were reviewed.
Objective
Well appearing. Left knee without erythema or effusion. Active range of motion is preserved. Mild anterior tenderness is present. The patient bears weight without assistance.
Assessment
Left knee pain with an activity-related pattern. The cause is not yet established. History and examination findings were discussed with the patient.
Plan
An individualized activity plan was discussed. Follow-up is planned in two weeks to reassess symptoms and function. The patient was advised to seek earlier evaluation for fever, a hot or swollen joint, inability to bear weight, or worsening symptoms.
A common documentation question
Is a SOAP note the same as a progress note?
SOAP is one way to organize a progress note. A progress note can also use a problem-oriented or narrative format. Choose the structure that makes the encounter and decisions easiest to follow.
GO DEEPER / CONDITION-SPECIFIC PLANS
Treatments, doses & follow-up
A note style does not determine a treatment. Explore the condition-specific examples for sourced adult dosing references, clinical reasoning, and follow-up plans.