# Eluve SOAP Note Details by Specialty

Reminders of what to dictate in each SOAP section, by specialty, to keep your
documentation complete. Paste one into Eluve as a custom template, or use it as a
quick dictation reference. Adapt to your specialty, payer, and jurisdiction. These
are documentation prompts, not clinical or coding guidance.

---

## Allergy & Immunology (SOAP)

**Subjective**
- Allergy/immunologic complaint with timeline and seasonality
- suspected triggers and exposures
- prior reactions and severity
- current medications (antihistamines, steroids, biologics)
- environmental and occupational history

**Objective**
- Vitals
- focused exam of skin, nasal mucosa, conjunctiva, and chest
- in-office testing (skin-prick/intradermal, spirometry, peak flow)
- prior IgE and lab results

**Assessment**
- Diagnosis and reasoning (allergic rhinitis, asthma, urticaria, anaphylaxis risk)
- control status
- ICD-10 per problem

**Plan**
- Avoidance guidance
- pharmacotherapy
- immunotherapy plan
- anaphylaxis action plan and epinephrine
- testing ordered
- follow-up interval

---

## Cardiology (SOAP)

**Subjective**
- Cardiac complaint (chest pain, dyspnea, palpitations, syncope) with onset and character
- exertional tolerance
- cardiac risk factors
- current cardiac medications and adherence

**Objective**
- Vitals including BP in both arms
- cardiac, pulmonary, and vascular exam
- edema
- ECG
- echo, stress, and lab results reviewed

**Assessment**
- Diagnosis and reasoning (CAD, heart failure, arrhythmia, hypertension)
- risk stratification
- ICD-10 per problem

**Plan**
- Medication changes
- diagnostics ordered (echo, stress test, monitor)
- procedures or referrals
- risk-factor modification
- follow-up

---

## Chiropractic (SOAP)

**Subjective**
- Chief complaint and mechanism
- pain scale and quality
- aggravating and relieving factors
- activities of daily living affected

**Objective**
- Posture and gait
- palpation findings
- ranges of motion
- orthopedic and neurologic tests
- segmental levels addressed

**Assessment**
- Diagnosis
- subluxation/segmental findings
- clinical rationale
- response to prior care

**Plan**
- Adjustments/manipulation by region
- modalities
- home care
- visit frequency and re-exam interval

---

## Dermatology (SOAP)

**Subjective**
- Skin complaint with lesion timeline and evolution
- symptoms (itch, pain)
- prior treatments
- sun-exposure and skin-cancer history
- relevant medications

**Objective**
- Full or regional skin exam
- lesion morphology (type, size, color, distribution, borders)
- dermoscopy
- body-site diagram
- procedures (biopsy) with site

**Assessment**
- Diagnosis and differential
- benign versus concerning features
- pathology pending
- ICD-10

**Plan**
- Topical or systemic therapy
- procedure plan
- biopsy/pathology follow-up
- sun-protection counseling
- recheck interval

---

## Emergency Medicine (SOAP)

**Subjective**
- Chief complaint and HPI
- symptom onset and severity
- pertinent ROS
- PMH, medications, allergies
- mode of arrival
- code status

**Objective**
- Vitals and trends
- focused exam by system
- ECG
- point-of-care, lab, and imaging results
- reassessments

**Assessment**
- Working diagnosis and differential
- risk stratification
- clinical course
- medical decision-making complexity

**Plan**
- Interventions and response
- consults
- disposition (admit, discharge, transfer)
- return precautions
- follow-up

---

## Endocrinology (SOAP)

**Subjective**
- Endocrine complaint
- symptom review (weight, energy, thirst, menstrual changes)
- glucose and BP logs
- current medications and insulin
- adherence and hypoglycemia episodes

**Objective**
- Vitals and BMI
- focused exam (thyroid, skin, feet, neuro)
- labs (A1c, TSH, lipids, hormone panels)
- CGM or glucose data

**Assessment**
- Diagnosis and control status (diabetes, thyroid, adrenal, bone)
- complication screening
- ICD-10 per problem

**Plan**
- Medication titration and targets
- labs ordered
- lifestyle counseling
- screening
- follow-up interval

---

## ENT / Otolaryngology (SOAP)

**Subjective**
- ENT complaint (hearing, ear pain, nasal, throat, voice, dizziness)
- duration
- prior treatments
- relevant history

**Objective**
- Head and neck exam
- otoscopy
- nasal endoscopy/rhinoscopy
- oropharynx
- neck and lymph-node exam
- audiogram or scope findings

**Assessment**
- Diagnosis and differential with laterality
- ICD-10

**Plan**
- Medical therapy
- procedures (cerumen removal, scope, biopsy)
- imaging or audiology ordered
- surgical planning
- follow-up

---

## Family Medicine (SOAP)

**Subjective**
- HPI in the patient's words
- ROS
- current medications
- allergies
- social and family history
- preventive-care concerns

**Objective**
- Vitals
- focused exam by system
- in-visit results
- screening measures

**Assessment**
- Problem list with clinical reasoning
- chronic-disease control
- ICD-10 per problem

**Plan**
- Orders, prescriptions, referrals
- patient education
- preventive care due
- follow-up interval

---

## Gastroenterology (SOAP)

**Subjective**
- GI complaint (abdominal pain, bowel changes, reflux, bleeding)
- diet and weight change
- medications
- prior scopes and imaging
- family GI/cancer history

**Objective**
- Vitals
- abdominal exam
- rectal exam if indicated
- labs (LFTs, CBC)
- imaging or endoscopy findings

**Assessment**
- Diagnosis and differential
- severity and risk
- ICD-10

**Plan**
- Medications
- dietary guidance
- endoscopy or imaging ordered
- labs
- follow-up and screening intervals

---

## Internal Medicine (SOAP)

**Subjective**
- HPI
- comprehensive ROS
- chronic-problem updates
- current medications and adherence
- allergies
- social history

**Objective**
- Vitals
- complete or focused exam by system
- in-visit and recent results

**Assessment**
- Problem list with reasoning across comorbidities
- control status
- ICD-10 per problem

**Plan**
- Medication management
- diagnostics
- referrals
- preventive care
- follow-up

---

## Neurology (SOAP)

**Subjective**
- Neurologic complaint (headache, weakness, numbness, seizure, memory) with onset and course
- triggers
- current neuro medications
- functional impact

**Objective**
- Mental status
- cranial nerves
- motor and sensory exam
- reflexes
- coordination and gait
- imaging, EEG, or EMG results

**Assessment**
- Localization and diagnosis/differential with clinical reasoning
- ICD-10

**Plan**
- Medications
- diagnostics (MRI, EEG, EMG, LP)
- referrals
- safety counseling
- follow-up

---

## OB/GYN (SOAP)

**Subjective**
- Reproductive/gynecologic complaint or prenatal update
- LMP and gestational age
- menstrual and obstetric history
- contraception
- symptoms
- current medications

**Objective**
- Vitals (BP, weight)
- abdominal and pelvic exam
- fundal height and fetal heart rate if prenatal
- Pap, lab, and ultrasound results

**Assessment**
- Diagnosis or pregnancy status and dating
- risk factors
- ICD-10

**Plan**
- Management and prescriptions
- screening (Pap, labs, ultrasound)
- prenatal schedule
- counseling
- follow-up

---

## Oncology (SOAP)

**Subjective**
- Cancer history and current treatment phase
- symptom and toxicity review
- performance status
- pain
- current regimen and tolerance

**Objective**
- Vitals and weight
- focused exam
- labs (CBC, CMP, tumor markers)
- imaging or restaging results
- ECOG status

**Assessment**
- Diagnosis with stage
- treatment response
- toxicity grading
- ICD-10

**Plan**
- Treatment plan and cycle
- supportive care
- labs and imaging
- dose adjustments
- goals-of-care discussion
- follow-up

---

## Ophthalmology (SOAP)

**Subjective**
- Eye complaint (vision change, pain, redness, floaters) with onset and laterality
- prior eye history and surgery
- current drops and medications

**Objective**
- Visual acuity
- intraocular pressure
- pupils
- external and slit-lamp exam
- dilated fundus exam
- OCT or visual fields

**Assessment**
- Diagnosis by eye (OD/OS/OU) and differential
- ICD-10

**Plan**
- Drops or medications
- procedures or laser
- imaging
- referral
- follow-up interval

---

## Orthopedics (SOAP)

**Subjective**
- Musculoskeletal complaint with mechanism or injury
- pain (location, NPRS)
- functional limits
- prior treatment and imaging

**Objective**
- Inspection and palpation
- ROM and strength
- special tests by joint
- neurovascular status
- imaging findings

**Assessment**
- Diagnosis with laterality
- operative versus nonoperative reasoning
- ICD-10

**Plan**
- Conservative care (bracing, PT, injections)
- surgical planning and consent
- imaging
- activity restrictions
- follow-up

---

## Pediatrics (SOAP)

**Subjective**
- Caregiver/patient concern with symptom timeline
- feeding, sleep, and behavior
- immunization status
- developmental concerns
- medications and allergies

**Objective**
- Growth parameters and percentiles
- vitals
- age-appropriate exam
- developmental screening

**Assessment**
- Diagnosis and differential
- growth and development assessment
- ICD-10

**Plan**
- Treatment with weight-based dosing
- immunizations
- anticipatory guidance
- screening
- follow-up

---

## Physical Therapy (SOAP)

**Subjective**
- Patient-reported status and change since last visit
- pain (NPRS) with location and laterality
- functional limitations
- home-exercise-program compliance
- new complaints

**Objective**
- ROM (degrees by joint/side)
- manual muscle testing grades
- special tests
- standardized outcomes (LEFS/ODI/DASH) with change from baseline
- interventions with CPT code and exact timed minutes

**Assessment**
- Skilled clinical reasoning
- progress toward goals
- medical necessity for continued skilled care
- response and barriers

**Plan**
- Frequency and duration
- planned progression
- next-visit focus
- plan-of-care certification/recertification status
- progress-report due date

---

## Psychiatry & Mental Health (SOAP)

**Subjective**
- Presenting concerns
- mood, anxiety, sleep, and appetite
- safety (suicidal/homicidal ideation)
- stressors
- substance use
- current psychiatric medications and adherence
- therapy

**Objective**
- Mental status exam (appearance, behavior, speech, mood/affect, thought, cognition, insight)
- screening scores (PHQ-9, GAD-7)

**Assessment**
- Diagnosis and differential (DSM-5)
- risk assessment
- ICD-10

**Plan**
- Medication management
- therapy or referral
- safety plan
- labs and monitoring
- follow-up interval

---

## Pulmonology (SOAP)

**Subjective**
- Respiratory complaint (dyspnea, cough, wheeze, sputum)
- triggers
- smoking and exposure history
- inhaler use and adherence
- oxygen use

**Objective**
- Vitals including SpO2
- respiratory and cardiac exam
- spirometry or PFTs
- imaging
- ABG if relevant

**Assessment**
- Diagnosis (asthma, COPD, ILD, infection)
- severity and control
- ICD-10

**Plan**
- Inhaler and medication plan
- oxygen
- diagnostics (PFT, imaging)
- pulmonary rehabilitation
- action plan
- follow-up

---

## Rheumatology (SOAP)

**Subjective**
- Joint or systemic complaint
- pattern and duration of pain and stiffness
- functional impact
- systemic symptoms
- current DMARDs/biologics and tolerance

**Objective**
- Joint exam (swelling, tenderness, ROM)
- skin and nail findings
- extra-articular findings
- labs (ESR/CRP, autoantibodies)
- imaging

**Assessment**
- Diagnosis and differential
- disease activity
- ICD-10

**Plan**
- DMARD or biologic management
- monitoring labs
- imaging
- injections
- patient education
- follow-up

---

## Urgent Care (SOAP)

**Subjective**
- Chief complaint and HPI with onset and severity
- pertinent ROS
- PMH, medications, allergies
- tetanus status if injury

**Objective**
- Vitals
- focused exam
- point-of-care testing (rapid strep, flu, urinalysis, glucose)
- in-visit imaging or results

**Assessment**
- Working diagnosis and differential
- severity and red-flag assessment
- ICD-10

**Plan**
- Treatment given
- prescriptions
- procedures (laceration repair, splint)
- work/school note
- ED referral criteria
- return precautions
- follow-up