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Sample SOAP Note

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A sample SOAP note showing typical output of ezChartWriter is presented below. Note that your charts can also be printed/exported in ExamSheet format.


Record of Examination        Ima K Doktor, OD PS

 Dr Ima Doktor and Associates


 PATIENT:        Donald I. Smith        DOB: 10/21/1966        GENDER: M        CHART#:        1751

 ENCOUNTER DATE: 10/30/2009        PROVIDER:        Doktor, Ima K



 Current and past history is unremarkable for ocular diseases, injuries and amblyopia.   In addition there is no history

 of ocular surgery.


 Unremarkable for past major illnesses, past surgeries or injuries.    Patient denies diabetes, hypertension, heart

 disease and lung disease.  Denies thyroid problems, cancer, inflammatory and infections disease.


 Patient denies pertinent family history including blindness, glaucoma, macular degeneration and retinal detachment.

 In addition, pertinent systemic family history is unremarkable.


 No medications currently taken.


 No known drug allergies.


 46 yo M

 ENCOUNTER TYPE:  Comprehensive eye exam.  Refraction.

 PATIENT TYPE:  New Patient

 LAST EXAM:  One+ years ago.


 CHIEF COMPLAINT:  Updating spectacle Rx.  Reports decreased near acuity.

 OCULAR SYMPTOMS:  Patient denies double vision, flashes, floaters or other ocular symptoms of clinical


 MEDICAL HX:  Medical/Personal History from 10/30/09 reviewed.




     OD +0.75  -2.25  x 085

     OS +0.75  -1.00  x 090




    ACUITY Type:  ccDVA

      OD 20/25-

      OS 20/25


     OD +0.50  -2.25  x 085   20/20

     OS +0.50  -1.25  x 090   20/20

     OU 20/20  (Binocular Balanced)     Add +1.50  20/20 @ 16"


     OD +0.50  -2.25  x 085

     OS +0.50  -1.25  x 090    Add +1.50



  NEURO Patient is fully alert to time, place and person.  Recent and remote memory is fully intact.  Patient does not

 appear anxious or depressed.

  ADNEXA  Facial symmetry is normal.  Ocular adnexa (including eyelids, eyelashes, bone structure and lacrimal

 glands) appear normal.

  FIELDS TESTING  Patient demonstrates satisfactory peripheral fields by confrontation in both OD and OS.

  EOMS  Full, extensive, accurate and smooth movements are observed OU.

  COVER TEST  Orthophoria is observed at near (without correction).

  PUPILS  React briskly (3+) to direct and consensual stimuli; pupil size is normal, equal and round OU. There is no

 afferent pupillary defect.



  LIDS/LASHES  External inspection and slit-lamp exam noted...  Normal eyelids and lashes OU.

  SCLERA/EPISCLERA  Sclera appears white and quiet.

  CONJUNCTIVA  Slit lamp observations include...  Bulbar and palpebral conjunctiva are white, clear and without

 signs of inflammation.

  CORNEA  Slit lamp examination reveals... Normal tear film, epithelial surface, stroma and endothelium OU.

  IRIS  Slit lamp examination reveals...  Iris appears healthy, normal anatomy and convexity.

  ANTERIOR CHAMBER  Slit lamp examination reveals...  Chambers are clear, free of cells and flare.

  ANGLE ESTIMATE  Grade 3+, open angle OU.

  LENS  Slit lamp examination reveals...  No significant cataract formation or opacification.


     OD 13.0 mm

     OS 13.0 mm   @ 17:53



  OPTIC DISC  Normal color, size and shape with intact neuro-retinal rims 360 degrees. Flat and sharp borders

 noted, as well as grossly normal appearance of nerve fiber layer OU.

  CUP/DISC RATIO   OD  0.25 H/V;  OS  0.25 H/V

  MACULA  Bilateral examination reveals... Maculae of normal thickness, free of atrophic changes.

  VASCULATURE  Findings include... Vasculature does not show hemorrhages or exudates.  Normal A/V crossings

 observed OU.

  POSTERIOR POLE  Observations include... Normal fundus coloration and architecture observed within the primary

 arcades OU.

 [Undilated fundus examination, evaluated with direct opthalmoscope.]


 367.0 Hyperopia

 367.21 Astigmatism

 367.4 Presbyopia

 OCULAR STATUS;  Ocular health status unremarkable.


 REFRACTIVE PLAN:  First-time spectacle wear; multi-focal lenses.

     OD +0.50  -2.25  x 085

     OS +0.50  -1.25  x 090    Add +1.50

 RECOMMENDATION... anti-scratch coating.


 RTC in 1-2 years for complete eye exam.