Primary Care Documentation Templates
Free templates for family medicine and general practice: SOAP notes for common visits, normal and abnormal physical exam wording, and a quick screening reference.
What's covered
Primary care template categories
Templates for routine, acute and chronic-care visits.
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
Copy or download
SOAP note templates
Ready-to-use SOAP templates for common primary care visits. Copy one into your EHR, or download the full set as a PDF.
Annual physical exam
ANNUAL PHYSICAL EXAM (SOAP) 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
DIABETES FOLLOW-UP (SOAP) 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
UPPER RESPIRATORY INFECTION (SOAP) 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.
Exam wording
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
Preventive screening reference
Evidence-based screening and prevention guidelines for primary care.
| Condition | Criteria | Frequency | Action |
|---|---|---|---|
| Hypertension screening | Adults ≥18 years | Annually if 40+ or at increased risk; every 3–5 years if 18–39 with normal BP | Measure BP (confirm outside the office), lifestyle counseling, consider medication if indicated |
| Diabetes screening | Adults 35–70 years with overweight or obesity (BMI ≥25) | Every 3 years if normal | Fasting glucose or HbA1c, lifestyle counseling |
| Cholesterol screening | Adults 40–75, or earlier with risk factors | Every 4–6 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 40–74 years | Every 2 years | Order mammogram, discuss benefits and risks |
Guidelines change
Documentation tips
Primary care notes that hold up
Best practices for efficient, 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 the billing level
- Missing follow-up instructions
- Vague or non-specific assessments
- Delayed documentation affecting accuracy
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