SOAP Note Template (Internal Medicine)
Published: 10/22/2025
About this template:
This internal medicine SOAP note template helps internists efficiently document comprehensive patient evaluations. It provides a structured approach for managing complex medical cases, multiple comorbidities, and diagnostic challenges. The template supports detailed documentation of systems review, differential diagnoses, and evidence-based treatment plans, making it ideal for both hospital rounds and outpatient consultations.
Preview template
Subjective: The patient, a 68-year-old male with type 2 diabetes and COPD, presents for follow-up of recent hospital discharge for COPD exacerbation. He reports improved dyspnea but continues to have a productive cough with yellow sputum. Blood glucose readings have been elevated (180-220 mg/dL) since starting prednisone. He denies chest pain, fever, or worsening shortness of breath. Currently taking albuterol, tiotropium, metformin, and completing prednisone taper.
Objective: Vital signs stable with oxygen saturation 94% on room air. Lung examination reveals decreased breath sounds bilaterally with scattered expiratory wheezes, improved from prior visit. Cardiovascular examination unremarkable. Hemoglobin A1c drawn today is 7.8%, up from 7.1% three months ago.
Assessment and Plan:
- COPD with recent exacerbation: Continue current inhaler regimen, complete prednisone taper as prescribed
- Type 2 diabetes with poor control: Likely secondary to steroid use, will monitor closely and consider temporary increase in metformin dose
- Pulmonary rehabilitation referral placed to improve functional status
- Pneumococcal and influenza vaccination status verified and up to date
Patient Education:
- Reviewed proper inhaler technique and importance of medication adherence
- Discussed warning signs of COPD exacerbation requiring immediate medical attention
- Advised on smoking cessation resources (patient quit 2 years ago, encouraged continued abstinence)
Follow-up scheduled in 4 weeks to reassess glucose control and respiratory status.
