SOAP Note

**Progress Note – [patient name], DOB: [date of birth]** [date of input] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Format as YYYY/MM/DD.) **Subjective:** - [reason for consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include specific musculoskeletal concerns such as joint pain, stiffness, injuries, deformities, etc.) - [history of presenting complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include onset, duration, severity, aggravating/alleviating factors, associated symptoms, previous trauma or treatment.) - [physiotherapy progress] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include whether progressing well or poorly.) - [symptom evolution and general progress since last visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Objective:** - **Vascular:** [vascular findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include pedal pulses, edema, varicose veins, capillary refill.) - **Musculoskeletal:** [musculoskeletal findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include inspection, palpation, ROM, strength, joint stability, deformity, tenderness.) - **Neurological:** [neurological findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include nerve function, vibratory sensation, protective sensation, paresthesia.) - **Dermatological:** [dermatological findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include skin/nail changes, wounds, calluses, dryness.) - [surgical wound appearance] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include presence of malodor, crepitus, erythema, drainage, signs of systemic infection.) - [investigation results] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include imaging, labs, and relevant findings.) **Assessment & Plan:** [1. Podiatric issue or condition] - [diagnosis and rationale] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Base on subjective and objective findings.) - [planned investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include imaging or tests for diagnosis/surgical planning.) - [planned surgical treatment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include type and nature of surgery, techniques if specified.) - [non-surgical treatment plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include physiotherapy, casting, bracing, medications, lifestyle changes.) - [referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include referrals to rheumatology, physio, pain, etc.) "Additional Podiatric Issues or Conditions:" - [additional issue and associated plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Follow the same structure as above.) **Additional Notes:** - [patient education provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include condition, procedures, complications, rehab, and care importance.) - [patient or family concerns addressed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [informed consent discussion] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include discussion of diagnosis, treatment, alternatives, and material risks.) - [material risks discussed – version 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Risks may include infection, bleeding, damage to nerves/vessels, compartment syndrome, tourniquet pain, persistent pain, fistula, VTE, medical or anaesthetic complications.) - [material risks discussed – version 2] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Risks may include infection, bleeding, transfusion, nerve/vessel injury, leg length discrepancy, instability, implant issues, persistent pain, stiffness, need for reoperation, VTE, death.) - [material risks discussed – version 3] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Risks may include infection, bleeding, transfusion, nerve/vessel injury, stiffness, implant loosening, tourniquet pain, VTE, medical or anaesthetic complications, death.) **ICD code:** - [ICD-10 codes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **CPT code:** - [CPT codes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps — use only the transcript, contextual notes or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)