Case Note Templates Guide
A comprehensive guide to medical documentation formats and best practices
Common Formats
SOAP
The most widely used format for clinical documentation, providing a structured approach to patient encounters.
Subjective
Patient's reported symptoms and history
Example: "Patient reports 3-day history of frontal headache..."
Objective
Clinical findings and measurements
Example: "BP 120/80, HR 72, Temp 37.2°C..."
Assessment
Clinical impression and diagnosis
Example: "Tension headache, no red flags identified..."
Plan
Treatment and follow-up
Example: "Prescribed paracetamol 1g QID, review in 1 week..."
SOAPIE
An extended version of SOAP that includes intervention and evaluation components.
Intervention
Actions taken during the visit
Example: "Administered trigger point injection..."
Evaluation
Assessment of intervention effectiveness
Example: "Patient reported 50% pain reduction..."
APSO
A reordered SOAP format that prioritizes assessment and plan for quick reference.
Assessment & Plan First
Immediate access to key clinical decisions
Example: "Diagnosis: Acute Bronchitis; Plan: Antibiotics..."
Supporting Information
Subjective and objective data follow
Example: "History and examination findings below..."
DAP
Data, Assessment, and Plan format - a streamlined approach to documentation.
Data
Combines subjective and objective information
Example: "3-day cough, fever 38.5°C, crackles in right base..."
Assessment & Plan
Combined assessment and management plan
Example: "Community-acquired pneumonia - start amoxicillin..."
Documentation Best Practices
Clarity
Use clear, concise language and avoid ambiguous terms
Completeness
Include all relevant information while maintaining brevity
Consistency
Maintain consistent format and terminology throughout
Specialized Formats
SBAR
Situation, Background, Assessment, Recommendation - commonly used in handovers and urgent communications.
Situation
Concise statement of the problem
Example: "72-year-old male presenting with acute chest pain for 2 hours"
Background
Relevant clinical history and context
Example: "History of hypertension, previous MI in 2019"
Assessment
Clinical evaluation and current status
Example: "Likely acute coronary syndrome, ECG shows ST elevation"
Recommendation
Proposed actions and timeline
Example: "Requesting immediate cardiology review and cath lab activation"
HAAP
History, Assessment, Appearance, Plan - useful for initial patient evaluations.
History
Patient's medical history and current symptoms
Example: "3-day history of worsening cough with green sputum"
Assessment
Clinical findings and test results
Example: "Bilateral chest crackles, fever 38.5°C"
Appearance
Patient's general appearance and vital signs
Example: "Appears unwell, mildly short of breath"
Plan
Treatment plan and follow-up
Example: "Start antibiotics, chest X-ray, review in 2 days"
Note Components
Chief Complaint
The primary reason for the patient's visit, in their own words.
Example: "Severe headache for the past 3 days"
Tips:
- Use patient's exact words when possible
- Keep it brief and focused
- Include duration if relevant
History of Present Illness
Detailed chronological description of the current problem.
Example: "Headache started gradually 3 days ago, initially mild but worsening. Associated with nausea and sensitivity to light. No fever or neck stiffness."
Key elements:
- Onset and progression
- Associated symptoms
- Aggravating/relieving factors
- Previous similar episodes
Review of Systems
Systematic review of body systems to identify other symptoms or problems.
Example: "Constitutional: Denies fever, fatigue. Respiratory: No cough or SOB. Cardiovascular: No chest pain..."
Systems to cover:
- Constitutional symptoms
- Major organ systems
- Relevant associated symptoms
Physical Examination
Objective findings from the clinical examination.
Example: "Vitals: BP 120/80, HR 72, Temp 37.2°C. Alert and oriented. Heart: Regular rhythm, no murmurs..."
Key components:
- Vital signs
- General appearance
- Systematic examination findings
- Relevant negative findings