SOAP Note · Internal Medicine
SOAP Note · Maya Chen
Clinic SOAP — pertinent ROS, complication screen, return precautions.
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Draft
Starter set, then every specialty × every document. Open as a draft and edit. Full finished pages live under Example.
Progress Note · Internal Medicine
Progress Note · Harold Pike
Inpatient progress — problem-based A/P, overnight events, numbers that change the plan.
Discharge Summary · Internal Medicine
Discharge Summary · Omar Rahman
Discharge — new meds with duration, timed follow-up, red flags.
History & Physical · Family Medicine
History & Physical · Priya Nair
New-patient H&P — health maintenance plus the actual problem.
Procedure Note · General Surgery
Procedure Note · Marcus Bell
Procedure — consent, timeout, specimen, Tdap.
Consultation · Psychiatry
Consultation · Daniel Reeves
Consult + safety — MSE, collateral, a clear hold vs no-hold rec.
Consultation · Neurology
Consultation · Robert Hale
Time-critical consult — NIHSS, clock, answer in sentence one.
SOAP Note · Pediatrics
SOAP Note · Noah Patel
Pediatrics — age in months, kg, mg/kg math, vaccines.
SOAP Note · Obstetrics & Gynecology
SOAP Note · Camila Rojas
OB — G/P, EGA, FHR, shots, next test.
SOAP Note · Emergency Medicine
SOAP Note · Keisha Brooks
ED MDM — worst case, re-eval, consult, disposition.
All combinations · 128
Internal Medicine: Open with a one-liner an intern would use on rounds.
SOAP Note · Internal Medicine · crafted
SOAP Note · Maya Chen
Clinic SOAP: one-liner, pertinent ROS, complication screen, numbered plan with return precautions.
Progress Note · Internal Medicine · crafted
Progress Note · Harold Pike
Inpatient progress: problem-based A/P, overnight events, numbers that change the plan.
History & Physical · Internal Medicine
History & Physical · Harold Pike
Full intake once: history, focused exam, health maintenance, problem list.
Discharge Summary · Internal Medicine · crafted
Discharge Summary · Omar Rahman
Discharge a US intern would sign: hospital course, new meds with duration, timed follow-up, red flags.
Procedure Note · Internal Medicine
Procedure Note · Harold Pike
Indication, consent, timeout, steps, findings, specimen, disposition.
Consultation · Internal Medicine
Consultation · Harold Pike
Answer the question in sentence one of the impression, then actionable recs.
Referral Letter · Internal Medicine
Referral Letter · Harold Pike
The ask, the workup already done, what you want back — not a chart dump.
Medication Plan · Internal Medicine
Medication Plan · Harold Pike
What changed today, why, allergies as reactions, counseling the patient heard.