Private GP SOAP note
1Subjective
- The reason for the visit, in the patient's own words where they are useful.
- How long it has been going on.
- Onset, course and what makes it better or worse.
- What the patient has already tried, and what they hope this visit achieves.
- Relevant past medical and surgical history.
- Current medicines, including anything bought over the counter.
- Allergies and the reaction each one caused, or a record that none are known.
2Objective
- Temperature, pulse, blood pressure and oxygen saturation where relevant.
- Findings on examination of the system involved, including relevant negatives.
3Assessment
- The working diagnosis, and the differentials still being considered.
- The clinician's reasoning, in a sentence or two.
4Plan
- Investigations requested, and who follows up the result.
- Treatment agreed, as prescribed in the prescribing record.
- Any referral, and whether a letter to the registered GP is needed.
- What should prompt the patient to get back in touch, and how.
- When the next review is due.
