SOAP Note Template (Family Medicine)
Published: 10/22/2025
About this template:
Built for comprehensive first visits in family medicine, this template guides you through a structured note: patient history and symptoms, focused exam findings, labs and studies, and a complete review of systems. It streamlines documentation across body systems so you can clearly capture clinical reasoning, establish working diagnoses, and outline a concrete plan for treatment and follow-up. Ideal for new patient consults, it supports a whole-person approach and pairs seamlessly with Scope’s AI scribe to make thorough notes faster and more consistent.
Preview template
Subjective:
52-year-old female, new patient establishing care. Chief complaint: 6 months of fatigue and occasional palpitations. Medical history: hypothyroidism (on levothyroxine 100mcg), hypertension (on lisinopril 10mg). Family history: diabetes and heart disease. Works as accountant, high stress lately. Denies chest pain, shortness of breath, or syncope.
Objective: BP 128/82, pulse 76 regular, BMI 28.5. Cardiovascular and lung exams normal. Thyroid non-enlarged, no nodules.
Assessment and Plan:
- Fatigue and palpitations: Order TSH, CBC, metabolic panel, ECG to rule out thyroid issues, anemia, or arrhythmia
- Hypothyroidism: Check levels and adjust medication if needed
- Hypertension: Well-controlled, continue current medication
- Weight management: Discussed lifestyle modifications, nutrition referral offered
- Health maintenance: Mammogram and lipid panel ordered
Patient Education:
- Explained workup for fatigue symptoms
- Discussed stress management and cardiovascular risk reduction
- Reviewed medication adherence
Follow-up scheduled in 2 weeks to review test results and adjust treatment plan as needed. Patient encouraged to call sooner if palpitations worsen or new symptoms develop. Patient verbalizes understanding and agreement with plan.
