SOAP documentation for an Alberta family-medicine walk-in encounter
Use a contemporaneous, factual, patient-specific note that records the clinical reasoning, advice, treatment, safety-netting, follow-up arrangements, clinician identity, date and time.
S — Subjective
- Record the presenting concern in the patient’s words, relevant history of the current problem, onset, duration, severity, associated symptoms, aggravating or relieving factors, relevant past medical and psychiatric history, medications, allergies, substance use, pregnancy status where relevant, and pertinent family and social history.
- Document relevant risk assessment, including self-harm or suicide risk, violence risk, safeguarding concerns, and capacity where clinically indicated.
- For possible domestic abuse, record the disclosure or observed concern, immediate safety issues, children or vulnerable adults affected, the patient’s wishes, and any discussion of referral or support; do not document in a way that could increase the patient’s risk if records are accessed by an abusive person. NICE CKS
O — Objective
- Document observable findings and measurable data, including vital signs, general appearance, examination findings, point-of-care tests, investigations reviewed, and relevant negative findings.
- State whether a chaperone was offered or present for intimate examinations, including their name and role where applicable.
- Separate observed facts from patient-reported symptoms and from clinical interpretation.
A — Assessment
- Record the working diagnosis or differential diagnosis, clinical severity, relevant risk formulation, and the rationale linking the history and examination to the assessment.
- Where diagnostic uncertainty remains, document this explicitly and identify the features that would alter the differential diagnosis or require escalation.
- For patients reporting domestic abuse, assess immediate danger and safeguarding needs, with particular attention to children and vulnerable adults. NICE CKS
P — Plan
- Document investigations ordered, treatment initiated or changed, dose and duration of prescribed medicines, non-pharmacological advice, referrals, work or school advice, and patient information provided.
- Record shared decision-making, including material benefits, harms, alternatives, and any treatment or referral declined by the patient.
- Provide explicit safety-netting: what symptoms or changes should prompt urgent reassessment, where to seek help, and the planned follow-up clinician, setting, and timeframe.
- Where domestic abuse is identified, offer appropriate support and referral, address immediate safety, and consider safeguarding action for children or vulnerable adults. NICE CKS
Concise walk-in template
S: “Patient reports [chief concern] for [duration], with [key positives] and denies [key negatives]. Relevant history: [conditions/medications/allergies/social factors]. Risk: [suicide/self-harm/violence/safeguarding/capacity assessment if relevant].”
O: “Vitals: [values]. Examination: [findings]. Tests/investigations: [results or pending]. Chaperone: [offered/present/not required].”
A: “Most likely [diagnosis]; differentials [list]. Clinical risk is [low/moderate/high] because [brief rationale].”
P: “Discussed [options]. Agreed [medication/intervention/investigation/referral]. Safety-net: attend ED/call emergency services/return to clinic for [specific red flags]. Follow-up: [provider/service] within [timeframe]. Patient understands and agrees/declines [specified element].”