"Soap Note Template - Amc"

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SOAP NOTE
Patient Name:________________________________________________________________________________
Date:______________
Age:________
Sex:_____
SUBJECTIVE: (Mechanism of injury (MOI), chief complaint (C/C))
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
OBJECTIVE: (Patient exam findings, Vital Signs, AMPLE History)
Vital Signs:
TIME:
_____________ _____________ _____________ _____________
LOC:
_____________ _____________ _____________ _____________
RR:
_____________ _____________ _____________ _____________
HR:
_____________ _____________ _____________ _____________
SKIN (CTM)
_____________ _____________ _____________ _____________
Patient Exam: Describe locations of pain, tenderness, injuries, Pertinent negatives
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
AMPLE:
Allergies:
Medications:
Pertinent Medical History:
Last Oral Intake:
Events leading to accident:
ASSESSMENT: (problem list)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
PLAN: (plan for each problem on list, evac route, bivouac location)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
Form completed by:____________________________________________
SOAP NOTE
Patient Name:________________________________________________________________________________
Date:______________
Age:________
Sex:_____
SUBJECTIVE: (Mechanism of injury (MOI), chief complaint (C/C))
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
OBJECTIVE: (Patient exam findings, Vital Signs, AMPLE History)
Vital Signs:
TIME:
_____________ _____________ _____________ _____________
LOC:
_____________ _____________ _____________ _____________
RR:
_____________ _____________ _____________ _____________
HR:
_____________ _____________ _____________ _____________
SKIN (CTM)
_____________ _____________ _____________ _____________
Patient Exam: Describe locations of pain, tenderness, injuries, Pertinent negatives
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
AMPLE:
Allergies:
Medications:
Pertinent Medical History:
Last Oral Intake:
Events leading to accident:
ASSESSMENT: (problem list)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
PLAN: (plan for each problem on list, evac route, bivouac location)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
Form completed by:____________________________________________