Objective Soap Note

SOAP Note

Prepared by: Andrew M. Kreutzer, NexGen Builders

This is a subjective, objective, assessment, and plan (SOAP) note for Lucas Moore, a 20-year-old male with listed symptoms. This tool guides clinicians in capturing objective data and observations, essential for an accurate diagnosis and effective session planning.

Subjective	Objective	Assessment	Plan
Patient name: Lucas Moore Age: 20 years Height: 5'8" Weight: 150 lbs Symptoms presented: (specify symptoms here)	Vital signs: BP, pulse, temperature (Specify measurements here) Physical exam results Laboratory results	Diagnosis based on history, physical exam, lab results (specify diagnosis here)	Create treatment plan based on the diagnosis Note management options including medications, therapies, lifestyle modifications, etc.

Subjective

Objective

Assessment

Plan

Patient name: Lucas Moore
Age: 20 years
Height: 5'8"
Weight: 150 lbs
Symptoms presented: (specify symptoms here)

Vital signs: BP, pulse, temperature (Specify measurements here)
Physical exam results
Laboratory results

Diagnosis based on history, physical exam, lab results (specify diagnosis here)

Create treatment plan based on the diagnosis
Note management options including medications, therapies, lifestyle modifications, etc.

Document created on (specify date here, 2050 onwards)