Family medicine SOAP notes: five worked examples

The SOAP-template guide covers the shape of a note. This one covers the substance. Below are five worked examples in the visit types family medicine sees every week — a viral upper respiratory infection, a routine type 2 diabetes follow-up, an anxiety/depression med check, acute low back pain, and a well-child visit. Every example is tight enough to fit on one screen and complete enough to paste into your EHR with only minimal editing. ICD-10 codes are suggested in the plan where they add value.

Example 1 — Viral URI (32F)

S: 32yo F with 4 days of progressive sore throat and non-productive cough. Denies fever, chills, dyspnea, or hemoptysis. Reports fatigue and mild frontal headache. No sick contacts identified; not tested for COVID or strep. PMH: seasonal allergies. Meds: loratadine PRN.

O: T 37.2, HR 76, RR 14, BP 118/72, SpO2 99%. General: well-appearing, comfortable. HEENT: erythematous posterior pharynx without exudate; tender anterior cervical lymphadenopathy. Lungs: clear bilaterally. Cardiac: RRR, no murmurs. Rapid strep negative.

A: 1. Acute viral upper respiratory infection (J06.9). Rapid strep negative reduces GAS pharyngitis to below-threshold. 2. Allergic rhinitis (J30.9), contributing.

P: 1. Supportive care: fluids, rest, acetaminophen 500-1000mg q6h PRN. RTC or ED if dyspnea, high fever, or symptoms persist >10 days. Patient counseled on red flags. 2. Continue loratadine daily during peak season; consider allergy referral if refractory next year.

Example 2 — Type 2 diabetes follow-up (58M)

S: 58yo M with T2DM (dx 2019) here for routine 3-month follow-up. Denies polyuria, polydipsia, blurred vision, or neuropathic symptoms. Adherent to metformin 1000mg BID and pravastatin 40mg qHS. Reports checking fingersticks 2-3x/week, averaging 130-160 mg/dL fasting. Diet inconsistent; walks 20 min 4x/week.

O: BP 132/80, HR 74, BMI 31.4 (down 1.2 from last visit). Feet: intact protective sensation with 10g monofilament, dorsalis pedis pulses 2+ bilaterally, no ulceration. HbA1c 7.3% (goal <7%). Fasting lipids: LDL 88, HDL 42, TG 168. Creatinine 0.9, eGFR >60. UACR 12 mg/g.

A: 1. Type 2 diabetes mellitus without complications (E11.9), suboptimal control, A1c above goal despite adherence. 2. Hyperlipidemia (E78.5), at goal on statin. 3. Overweight (E66.3), 6-lb weight loss since last visit — positive trend.

P: 1. Add empagliflozin 10mg daily (SGLT2i for glycemic + weight + cardiorenal benefit). Continue metformin. Recheck A1c in 3 months. Retinal exam annually — referral placed to ophthalmology. 2. Continue pravastatin. 3. Reinforce daily 30-min walk goal; referral to diabetes educator for MyPlate coaching. Patient counseled on empagliflozin side-effect profile including genital mycotic infection.

Example 3 — Anxiety/depression med check (41F)

S: 41yo F here for 6-week follow-up on sertraline 50mg daily started for GAD + moderate MDD. Reports improved sleep and less "on-edge" feeling. Mood 5/10 (was 3/10 at start). Denies SI/HI. No nausea, sexual side effects, or GI upset. PHQ-9 today 8 (was 14); GAD-7 today 7 (was 15). Working full-time; back to weekly running.

O: BP 118/74, HR 70. General: appropriate affect, no psychomotor changes. No thought disorder, delusions, or perceptual disturbance. Judgment and insight intact.

A: 1. Generalized anxiety disorder (F41.1) — improving, GAD-7 dropped 8 points. 2. Major depressive disorder, moderate (F33.1), single episode — improving, PHQ-9 dropped 6 points. Partial response.

P: 1. Increase sertraline to 75mg daily to push closer to remission. Discussed titration, expected 2-4 week window for effect, and continued avoidance of NSAIDs/alcohol during titration. 2. Continue weekly CBT with existing therapist. 3. RTC in 6 weeks or sooner PRN. Crisis line reviewed. Warm-hand-off scheduled with therapist post-visit.

Example 4 — Acute low back pain (34M)

S: 34yo M laborer with 3 days of lumbar back pain after lifting a heavy load at work. Pain 7/10, dull-aching, no radiation below the knee. Denies bowel/bladder changes, saddle anesthesia, fever, or weight loss. No prior back injury. Ibuprofen 400mg gives partial relief.

O: Ambulating without antalgic gait but stiffly. Lumbar paraspinal tenderness bilaterally; midline spinous processes non-tender. Range of motion limited by pain to 40° flexion. Straight-leg raise negative bilaterally at 60°. Neuro: strength 5/5 in all lower-extremity myotomes, sensation intact L2-S1, reflexes 2+ patellar and Achilles bilaterally.

A: Acute mechanical low back pain (M54.5) without red flags. No indication for imaging or specialist referral at this visit.

P: 1. Ibuprofen 600mg TID with food x 5-7 days. Add cyclobenzaprine 5mg qHS PRN for spasm x 5 days. 2. Stay active — bed rest >2 days worsens outcomes. Return to modified work duty with 20-lb lifting restriction x 1 week; letter provided. 3. Physical therapy referral if not improved in 2 weeks; MRI not indicated at this time. 4. RTC or ED for red-flag symptoms (fever, weakness, bowel/bladder change, saddle numbness). Handout given.

Example 5 — Well-child visit (4-year-old F)

S: 4yo F here for annual well-child visit accompanied by mother. Eating variety of foods, milk 16oz/day. Sleeps 11 hrs overnight without waking. Toilet-trained day and night. In preschool 4 half-days/week, mother reports she "loves it" and interacts well with peers. Speaks in complete sentences, using pronouns correctly. Draws recognizable people (head + limbs). No parental concerns.

O: Height 40 in (50th %ile), weight 36 lb (50th %ile), BMI 15.8 (50th %ile). BP 92/60. General: cooperative, playful. Skin: no rashes. HEENT: TMs clear, oropharynx no erythema, dentition intact with no caries visible. Cardiac: RRR, no murmur. Lungs: clear. Abdomen: soft, non-tender. GU: normal external genitalia. Development: age-appropriate on Denver-II screening.

A: 1. Well-child, 4-year (Z00.129) — appropriately grown and developing. 2. Immunizations up to date; DTaP #5, IPV #4, MMR #2, varicella #2 due at this visit.

P: 1. Administer age-4 immunization set today (DTaP, IPV, MMR, varicella). Discussed common post-vaccine side effects (mild fever, injection-site tenderness) and acetaminophen dosing. 2. Anticipatory guidance: booster/car-seat safety, choking hazards, screen-time limit ≤1 hr/day of age-appropriate content, brushing 2x/day with fluoride toothpaste, first dental visit if not already established. 3. RTC for 5-year well-child in 12 months; sooner PRN.

What makes a family-medicine SOAP good

Four things separate a great family-medicine note from a barely-passable one:

• The assessment commits. "URI, viral" is better than "possible URI vs. bacterial vs. allergic." Commit to a diagnosis and note the reasoning; a differential belongs in your head, not the chart.
• The plan cross-references the assessment. Each numbered plan item traces back to a numbered assessment item. No orphan interventions.
• ICD-10 codes are specific. "E11.9" (T2DM without complications) is worse than "E11.65" if there is documented hyperglycemia. Specificity affects reimbursement.
• Patient counseling is documented. "Patient counseled on medication side effects" or "handout given" makes the note defensible in a review.

Try it on your next visit

If you want notes like the above generated automatically from your recorded conversations, start the ezScribe 14-day trial. HIPAA-compliant, works with any EHR by copy-paste. See also the SOAP structure guide if you want to go deeper on why this format works.