Primary Care Template Categories
Comprehensive templates for all aspects of primary care practice
Routine Visits
Templates for common primary care encounters
- Annual Physical Exam
- Follow-up Visit
- Chronic Disease Management
- Preventive Care Visit
- Wellness Check
Acute Care
Templates for urgent and acute conditions
- Upper Respiratory Infection
- Acute Gastroenteritis
- Urinary Tract Infection
- Minor Injury Assessment
- Fever Evaluation
Chronic Conditions
Templates for ongoing condition management
- Diabetes Management
- Hypertension Follow-up
- Asthma Management
- Depression Screening
- Medication Review
SOAP Note Templates
Ready-to-use SOAP note templates for common primary care visits
Annual Physical Exam
SUBJECTIVE:
Patient presents for annual physical examination. Reports feeling [well/concerns]. Current medications: [list]. Allergies: [list]. Social history: [tobacco/alcohol/exercise]. Family history: [relevant updates].
OBJECTIVE:
Vital signs: BP [value], HR [value], Temp [value], Weight [value], BMI [value]. General appearance: [well-appearing/ill-appearing]. HEENT: [normal/abnormal findings]. Cardiovascular: [RRR/murmur]. Pulmonary: [clear/abnormal]. Abdomen: [soft/tender]. Extremities: [no edema/abnormal]. Neurologic: [intact/deficits].
ASSESSMENT:
1. Health maintenance - due for [screenings]. 2. [Chronic conditions] - stable/needs adjustment. 3. [New concerns] - [assessment]. Overall health status: [excellent/good/fair/poor].
PLAN:
1. Continue current medications. 2. Order [lab work/imaging/screenings]. 3. Lifestyle counseling: [diet/exercise/smoking cessation]. 4. Follow-up in [timeframe]. 5. Return PRN for concerns.
Diabetes Follow-up
SUBJECTIVE:
Patient with Type [1/2] diabetes returns for routine follow-up. Blood sugars: [range/pattern]. Adherence to medications: [good/poor]. Diet and exercise: [compliant/non-compliant]. Symptoms: [polyuria/polydipsia/blurred vision/none]. Foot care: [appropriate/needs education].
OBJECTIVE:
Vital signs: BP [value], Weight [value], BMI [value]. General appearance: [well]. Cardiovascular: [normal/abnormal]. Extremities: [pulses intact, no ulcers/abnormal findings]. Neurologic: [sensation intact/diminished]. Labs: HbA1c [value], glucose [value].
ASSESSMENT:
Type [1/2] diabetes mellitus - [well-controlled/poorly controlled]. HbA1c [value] ([improved/stable/worsened] from [previous value]). [Complications present/absent]: [retinopathy/nephropathy/neuropathy].
PLAN:
1. Continue [current diabetes medications]. 2. [Adjust/maintain] current regimen. 3. Diabetes education reinforced. 4. Order [labs/referrals]. 5. Follow-up in [3 months]. 6. Contact for blood sugar concerns.
Upper Respiratory Infection
SUBJECTIVE:
Patient presents with [duration] history of [cough/congestion/sore throat/runny nose]. Associated symptoms: [fever/headache/body aches/fatigue]. Severity: [mild/moderate/severe]. Previous treatments tried: [OTC medications/home remedies]. No recent travel or sick contacts.
OBJECTIVE:
Vital signs: Temp [value], BP [value], HR [value], O2 sat [value]. General appearance: [well/mildly ill]. HEENT: [nasal congestion/erythematous throat/normal TMs]. Neck: [no lymphadenopathy/tender nodes]. Pulmonary: [clear/rhonchi/wheezes]. No respiratory distress.
ASSESSMENT:
Viral upper respiratory infection. No evidence of bacterial infection. Symptoms consistent with [common cold/viral syndrome]. No complications noted.
PLAN:
1. Supportive care: rest, fluids, humidifier. 2. OTC medications: [acetaminophen/ibuprofen] for comfort. 3. [Throat lozenges/saline rinses]. 4. Return if symptoms worsen or persist >10 days. 5. Return for fever >101.5°F or difficulty breathing.
Physical Exam Templates
Standardized physical exam documentation for consistent clinical notes
Cardiovascular
Normal Findings:
Regular rate and rhythm, no murmurs, rubs, or gallops. PMI non-displaced. No peripheral edema. Pulses 2+ bilaterally.
Abnormal Findings Template:
Irregular rhythm, [systolic/diastolic] murmur grade [I-VI/VI], [location]. [Edema/no edema]. Pulses [diminished/absent] in [location].
Pulmonary
Normal Findings:
Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Good air movement. No respiratory distress.
Abnormal Findings Template:
[Wheezes/rales/rhonchi] in [location]. Diminished breath sounds [location]. [Tachypneic/dyspneic]. Use of accessory muscles.
Abdominal
Normal Findings:
Soft, non-tender, non-distended. Bowel sounds present. No hepatosplenomegaly. No masses palpated.
Abnormal Findings Template:
[Tender/distended] in [location]. [Hypoactive/hyperactive] bowel sounds. [Hepatomegaly/splenomegaly]. Mass palpated in [location].
Neurologic
Normal Findings:
Alert and oriented x3. Cranial nerves II-XII intact. Motor strength 5/5 throughout. Reflexes 2+ and symmetric. Sensation intact.
Abnormal Findings Template:
[Confused/disoriented]. CN [number] deficit: [description]. Motor strength [grade] in [location]. Reflexes [hyperactive/diminished]. Sensory deficit in [distribution].
Clinical Decision Support
Evidence-based screening and prevention guidelines for primary care
| Condition | Criteria | Frequency | Action |
|---|---|---|---|
| Hypertension Screening | Adults ≥18 years | Every 1-2 years if normal, annually if elevated | Measure BP, lifestyle counseling, consider medication if indicated |
| Diabetes Screening | Adults 35-70 years with BMI ≥25 | Every 3 years if normal | Fasting glucose or HbA1c, lifestyle counseling |
| Cholesterol Screening | Men 35+, Women 45+, or earlier if risk factors | Every 5 years if normal | Lipid panel, calculate cardiovascular risk, lifestyle counseling |
| Colorectal Cancer Screening | Adults 45-75 years | Colonoscopy every 10 years or FIT annually | Discuss screening options, order appropriate test |
| Mammography | Women 50-74 years | Every 2 years | Order mammogram, discuss benefits and risks |
Primary Care Documentation Tips
Best practices for efficient and compliant primary care documentation
Effective Strategies
- Use templates to ensure consistency and completeness
- Document medical decision-making clearly
- Include relevant negative findings
- Reference previous visits and ongoing issues
- Document patient education and counseling
Common Pitfalls
- ✗Copying forward notes without updates
- ✗Insufficient documentation for billing level
- ✗Missing follow-up instructions
- ✗Vague or non-specific assessments
- ✗Delayed documentation affecting accuracy