Free Objective Soap Note Design

Document with precision using our Objective SOAP Note Design Template, available at Template.net. This template emphasizes clear and concise recording of objective medical findings. It is fully editable and customizable, allowing you to tailor it to your unique documentation needs. Easily personalize this design editable in our AI Editor Tool, ensuring efficiency and accuracy in your workflow.

Vital Sign	Measurement	Notes
Heart Rate	78 beats per minute	Regular
Blood Pressure	120/80 mmHg	Normal
Respiratory Rate	16 breaths per minute	Unlabored
Temperature	98.6°F	Normal

Category	Findings
General Appearance	Well-groomed, no signs of distress
Cardiovascular	Regular heart rhythm, no murmurs or gallops
Respiratory	Clear lung sounds, no wheezing or crackles
Abdomen	Soft, non-tender, no masses or organomegaly
Musculoskeletal	Full range of motion in all joints, no swelling or deformity
Neurological	Alert and oriented x3, no focal deficits

Test	Result	Normal Range
Complete Blood Count (CBC)
Hemoglobin	14 g/dL	12–16 g/dL (female), 14–18 g/dL (male)
White Blood Cell Count	6,000/mm³	4,000–11,000/mm³
Platelets	250,000/mm³	150,000–450,000/mm³

Test	Result	Normal Range
Basic Metabolic Panel (BMP)
Sodium	140 mEq/L	135–145 mEq/L
Potassium	4.2 mEq/L	3.5–5.0 mEq/L
Creatinine	1.0 mg/dL	0.6–1.2 mg/dL
Glucose	90 mg/dL	70–100 mg/dL (fasting)

Test	Result	Normal Range
Liver Function Tests
AST (Aspartate Aminotransferase)	22 U/L	10–40 U/L
ALT (Alanine Aminotransferase)	24 U/L	7–56 U/L
Bilirubin	0.8 mg/dL	0.1–1.2 mg/dL

Free Objective Soap Note Design

I. Vital Signs

II. Physical Exam Findings

III. Laboratory Results

IV. Diagnostic Tests

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