1. Patient Introduction
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Chief Complaint (CC)
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Age, gender, and brief context (e.g., “Mr. Smith, a 52-year-old male, presents with chest pain.”)
2. History Taking
a. History of Present Illness (HPI)
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Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity (OLDCARTS)
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Associated symptoms
b. Past Medical History (PMH)
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Chronic conditions, surgeries, hospitalizations
c. Family History (FH)
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Genetically linked conditions (heart disease, diabetes, cancer)
d. Social History (SH)
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Smoking, alcohol, drug use, occupation, living conditions
e. Medications & Allergies
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Current medications, herbal supplements
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Known drug/food/environmental allergies
3. Review of Systems (ROS)
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Head-to-toe symptom checklist by system (e.g., cardiovascular, respiratory, GI, neuro)
4. Physical Examination
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Vital signs (BP, HR, RR, Temp, O2 Sat)
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Focused systems exam
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General appearance
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Heart & lungs
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Abdominal
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Neuro/MSK as needed
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Identify abnormal findings
5. Differential Diagnosis (DDx)
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List 3–5 possible diagnoses
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Rank by likelihood
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Justify each with signs/symptoms
6. Diagnostic Workup
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Labs (e.g., CBC, CMP, troponin)
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Imaging (X-ray, CT, MRI, US)
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Other tests (ECG, PFTs, cultures)
7. Final Diagnosis
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Confirmed by test results and clinical evidence
8. Management Plan
a. Pharmacologic
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Drug name, dose, route, frequency, duration
b. Non-Pharmacologic
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Lifestyle changes, physical therapy, counseling
c. Patient Education
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Diagnosis explanation, medication use, red flags
d. Follow-up
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Timeline and goals for reassessment
9. SOAP Note Documentation
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Subjective: HPI, ROS, PMH, SH, FH
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Objective: Vitals, physical exam, labs/imaging
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Assessment: DDx → final diagnosis
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Plan: Diagnostics, treatment, education, follow-up
10. Reflection & Clinical Reasoning Feedback
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What went well?
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What did you miss?
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What would you do differently?
