SOAP Note

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SOAP Note

Organizes a clinical encounter into Subjective, Objective, Assessment, and Plan sections.

See it in action
SOAP note sample with Subjective, Objective, Assessment, and Plan sections.

Output structure

  • Subjective
  • Objective
  • Assessment
  • Plan

Sample output

04-27 Clinical Note: New-Onset Severe Headache with Photophobia, Neck Stiffness, and Nausea

Date & Time: 2026-04-27 20:21:06

Patient: [Speaker 2]

Diagnosis:

Diagnosis History:

1. Medical History:

  • Hypertension diagnosed ~3 years ago; managed with diet/monitoring; well controlled; not on antihypertensive medications.
  • No surgical history.
  • No prior hospitalizations.
  • No known drug allergies.
  • Family history: Mother had migraines in her 20s–30s; father has hypertension; sister healthy; no children.
  • Social history: Smokes ~0.5 pack/day; denies alcohol use; married; postmenopausal.
  • Recent travel: One week prior, traveled to North Carolina for a family reunion; exposure to a sick 4-year-old who was taken to the emergency department (illness unspecified).

2. Medication History:

  • Current/prior for this complaint: Acetaminophen (Tylenol) and ibuprofen (Motrin); ineffective.
  • No chronic prescription medications.
  • No adverse drug reactions reported.
  • Insert more here

Subjective:

  • Chief complaint: Severe headache for 3 days.
  • Pain characteristics: Diffuse “all over” head pain with frontal predominance; constant; gradual onset then persistent without fluctuation; worsened by movement and light (photophobia).
  • Severity: 10/10, “worst headache,” unlike any prior headaches; unable to work; significant functional impairment.
  • Associated symptoms: Neck stiffness; shooting pain down the neck; nausea with two episodes of vomiting early in the course, worsened by movement.
  • Concerns: Worried about serious causes (e.g., brain tumor) due to an acquaintance’s seizures; insurance coverage concerns.

Objective:

  • No physical exam findings, vital signs, labs, or imaging documented in the transcript.
  • Plan to perform physical exam and testing, but not yet recorded.

Primary Diagnosis:

  • Assessment: New-onset severe headache with photophobia, nausea/vomiting, and neck stiffness, constant over 3 days. Differential includes migraine (family history), tension-type headache, and concerning causes such as meningitis/subarachnoid hemorrhage or other secondary etiologies given neck stiffness and severity. No definitive diagnosis recorded in the transcript.
  • Suspected Diagnosis: None at the moment

Plan:

  • Prescription: Insert more here
  • Next Steps/Examination:
  • Perform comprehensive physical and neurologic exam, including assessment of nuchal rigidity and meningeal signs.
  • Obtain vital signs (including temperature and blood pressure).
  • If red flags are present, consider urgent diagnostics: non-contrast head CT; if meningitis or subarachnoid hemorrhage remains suspected after imaging, consider lumbar puncture.
  • Evaluate for migraine features; if appropriate and secondary causes are ruled out, consider acute therapy (e.g., antiemetic, NSAID, triptan).
  • Office staff to verify current insurance coverage and benefits.
  • Follow-up Treatment Plan:
  • Arrange prompt follow-up after initial exam/testing to review results and adjust management.
  • If migraine is confirmed, discuss preventive strategies and trigger management; consider smoking cessation counseling.
  • Advise return/ER precautions for worsening headache, new neurologic deficits, persistent vomiting, fever, or confusion.