Internal Medicine: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Internal medicine SOAP notes require comprehensive documentation that addresses the full spectrum of adult patient care - from acute illness management to chronic disease optimization and preventive health maintenance. Internists serve as the central coordinators for complex patients with multiple comorbidities, making thorough documentation essential for care continuity, quality reporting, and optimal patient outcomes. This guide provides detailed instructions for documenting internal medicine encounters following AMA documentation guidelines and CMS 2026 requirements.

Unique Aspects of Internal Medicine Documentation

Internal medicine documentation differs from other specialties in several critical ways:

1. Comprehensive Care Coordination: Internists manage multiple chronic conditions simultaneously, requiring integrated documentation approaches
2. Complex Patient Populations: Patients often have 5+ chronic conditions with polypharmacy considerations
3. Preventive Care Integration: Health maintenance and USPSTF-guided screening must be documented alongside acute and chronic care
4. Chronic Disease Management: Diabetes, hypertension, and hyperlipidemia protocols require standardized documentation for quality measures
5. Medication Reconciliation: Comprehensive medication management is central to every encounter
6. Risk Stratification: Cardiovascular, diabetes, and cancer risk assessments guide preventive interventions
7. Quality Measures Reporting: MIPS/MACRA quality metrics require specific documentation elements
8. Care Transitions: Hospital follow-up and specialist coordination documentation is essential

Subjective Section (S)

The Subjective section in internal medicine must capture a comprehensive history that addresses both acute concerns and the ongoing management of chronic conditions, while also documenting health maintenance needs.

Subjective Section (S) Components

1. Chief Complaint:

   • Primary reason for visit with duration
   • May include multiple concerns for complex patients
   • Example: "Annual wellness visit with medication refill; also concerned about increased fatigue x 2 weeks"

2. History of Present Illness:

   • Detailed description of acute symptoms with OLDCARTS elements
   • Chronological narrative of symptom development
   • Impact on daily functioning
   • Example: "58-year-old male with progressive fatigue over 2 weeks. Reports needing to rest after climbing one flight of stairs. Associated with mild exertional dyspnea. No chest pain, orthopnea, or edema. No fever, weight loss, or night sweats."

3. Chronic Disease Review:

   • Status of each chronic condition since last visit
   • Symptom control assessment
   • Self-management behaviors (diet, exercise, monitoring)
   • Recent hospitalizations or ER visits
   • Example: "Diabetes: Blood sugars ranging 120-180 fasting per home log. No hypoglycemia. Checking BG 2x daily. Following diabetic diet with occasional lapses."

4. Comprehensive Review of Systems:

   • Constitutional: Weight changes, fatigue, fever, night sweats
   • HEENT: Vision changes, hearing, dental issues
   • Cardiovascular: Chest pain, palpitations, edema, claudication
   • Respiratory: Dyspnea, cough, wheezing
   • GI: Appetite, nausea, bowel changes, GERD symptoms
   • GU: Urinary symptoms, sexual function, menstrual history
   • Musculoskeletal: Joint pain, stiffness, weakness
   • Skin: Rashes, lesions, changes in moles
   • Neurological: Headaches, numbness, weakness, cognitive changes
   • Psychiatric: Mood, anxiety, sleep, stress
   • Endocrine: Heat/cold intolerance, polyuria, polydipsia
   • Hematologic/Lymphatic: Easy bruising, bleeding, lymphadenopathy

5. Medication Reconciliation:

   • Complete medication list with doses and frequencies
   • Adherence assessment for each medication
   • Side effects or concerns
   • OTC medications, supplements, and herbals
   • Medications from other providers
   • Example: "Patient reports taking metformin 1000mg BID as prescribed. Occasionally misses evening dose. No GI side effects. Using ibuprofen 400mg PRN for knee pain 3-4x weekly."

6. Health Maintenance History:

   • Cancer screenings: Colonoscopy, mammogram, Pap smear, lung CT, PSA
   • Immunizations: Flu, pneumonia, shingles, Tdap, COVID-19
   • Preventive labs: Lipid panel, HbA1c, metabolic panel
   • Lifestyle factors: Tobacco, alcohol, diet, exercise
   • Example: "Last colonoscopy 2020 (normal, repeat in 10 years). Received flu vaccine this season. Due for shingles vaccine. Walks 20 minutes daily."

7. Social History:

   • Living situation and support system
   • Employment and occupational exposures
   • Tobacco: Pack-years, current status, cessation interest
   • Alcohol: Quantity, frequency, CAGE if indicated
   • Substance use: Illicit drugs, prescription misuse
   • Diet and exercise patterns
   • Sleep habits

8. Family History:

   • First-degree relatives with major conditions
   • Age of onset for hereditary conditions
   • Causes of death in close relatives
   • Relevant for risk stratification (CAD, diabetes, cancer)

Example Subjective Section for Internal Medicine

Objective Section (O)

The Objective section in internal medicine requires a comprehensive physical examination with attention to findings relevant to chronic disease management, preventive care metrics, and acute concerns.

Objective Section (O) Components

1. Vital Signs:

   • Blood pressure (may need orthostatic if indicated)
   • Heart rate and rhythm
   • Respiratory rate
   • Temperature
   • Weight with comparison to prior visits
   • Height (annually for seniors - height loss)
   • BMI calculation
   • Oxygen saturation if indicated
   • Example: "BP 146/88 mmHg, HR 78 regular, RR 14, Temp 98.4F, Weight 248 lbs (stable), Height 5'11", BMI 34.6"

2. General Appearance:

   • Overall health status
   • Nutritional status
   • Apparent age vs. stated age
   • Level of distress
   • Affect and engagement

3. Complete Physical Examination:

   • HEENT: Eyes (fundoscopic for diabetics), ears, oropharynx
   • Neck: Thyroid, lymph nodes, carotid bruits
   • Cardiovascular: Heart sounds, murmurs, peripheral pulses, edema
   • Respiratory: Breath sounds, effort
   • Abdomen: Organomegaly, masses, tenderness, AAA (if indicated)
   • Extremities: Pulses, edema, skin changes, diabetic foot exam
   • Skin: Lesions, concerning moles, acanthosis nigricans
   • Neurological: Sensation (monofilament for diabetics), reflexes
   • Psychiatric: Mood, affect, cognition if indicated

4. Preventive Screening Results:

   • Recent cancer screening results
   • Immunization status
   • Risk assessment scores (ASCVD, Framingham)

5. Chronic Disease Metrics:

   • Blood pressure tracking
   • Weight trend
   • Diabetic foot exam findings
   • Point-of-care glucose if available

6. Laboratory Results:

   • Recent labs with dates and values
   • Trending of key values (A1c, lipids, renal function)
   • Abnormal values highlighted
   • Comparison to prior results

Example Objective Section for Internal Medicine

Assessment Section (A)

The Assessment section synthesizes clinical findings with attention to problem list management, disease severity, quality measure compliance, and risk stratification.

Assessment Section (A) Components

1. Problem List with ICD-10 Codes:

   • Active problems being addressed today
   • Chronic conditions requiring ongoing management
   • New diagnoses established

2. Disease Control Assessment:

   • At goal vs. not at goal for each chronic condition
   • Improvement, stable, or worsening status
   • Barriers to control identified

3. Risk Stratification:

   • ASCVD risk calculation
   • Diabetes complication risk
   • Cancer risk based on history
   • Falls risk if applicable

4. Quality Measures Assessment:

   • MIPS/MACRA relevant measures
   • Preventive care gaps
   • Chronic disease quality metrics (A1c, BP, LDL)

5. Clinical Reasoning:

   • Connection between symptoms and diagnoses
   • Differential diagnosis when indicated
   • Prognosis considerations

Example Assessment Section for Internal Medicine

Plan Section (P)

The Plan section must address each active problem with specific interventions, following evidence-based protocols for chronic disease management and preventive care.

Plan Section (P) Components

1. Chronic Disease Management Protocols:

   • Diabetes management (ADA guidelines)
   • Hypertension management (AHA/ACC guidelines)
   • Hyperlipidemia management (ACC/AHA cholesterol guidelines)
   • Specific medication adjustments with rationale

2. Medication Changes:

   • New medications with indication, dose, and instructions
   • Dose adjustments with rationale
   • Medications discontinued with reason
   • Drug interaction considerations

3. Preventive Care Orders:

   • Cancer screenings ordered (colonoscopy, mammogram, etc.)
   • Immunizations administered or ordered
   • Risk-based screenings (AAA ultrasound, lung CT)

4. Lifestyle Counseling:

   • Diet recommendations
   • Exercise prescription
   • Weight management plan
   • Tobacco/alcohol counseling

5. Care Coordination:

   • Specialist referrals with reason
   • Communication with other providers
   • Care team involvement

6. Laboratory and Diagnostic Orders:

   • Follow-up labs with timing
   • Imaging studies
   • Other tests indicated

7. Patient Education:

   • Topics discussed
   • Written materials provided
   • Teach-back confirmation

8. Follow-up Plan:

   • Return visit timing and purpose
   • Interim phone/portal check-ins
   • When to seek urgent care

Example Plan Section for Internal Medicine

AI-Assisted Documentation for Internal Medicine

As of 2025, 66% of healthcare providers utilize AI tools in their practice. AI scribes and ambient clinical intelligence are particularly valuable for internal medicine, where comprehensive documentation of multiple chronic conditions and preventive care is required.

How AI Helps Internal Medicine Documentation

• Comprehensive ROS capture: Accurately documents extensive review of systems discussions
• Medication reconciliation: Captures detailed medication lists with doses and adherence
• Chronic disease tracking: Documents status updates for multiple conditions
• Preventive care discussions: Records health maintenance counseling and decisions
• Care coordination notes: Captures referral discussions and care planning
• Patient education documentation: Records topics discussed and patient understanding

Internal Medicine-Specific AI Considerations

What AI captures well:

• Chief complaint and HPI narrative
• Detailed medication lists and dosages
• Review of systems responses
• Lifestyle counseling discussions
• Patient-reported symptoms and concerns
• Follow-up instructions

What requires careful review:

• Vital sign accuracy (especially BP readings)
• Laboratory values and trends
• Physical examination findings (ensure all systems documented)
• Medication doses and changes
• ICD-10 codes (verify specificity)
• Quality measure documentation elements
• Risk score calculations

Tips for Using AI with Internal Medicine Documentation

1. State medications clearly: "Lisinopril twenty milligrams once daily" not "lisinopril"
2. Verbalize lab values: "The A1c is eight point nine percent, up from seven point eight"
3. Document exam findings systematically: Work through each body system audibly
4. State assessment clearly: "The diabetes is uncontrolled with A1c above goal"
5. Specify preventive care status: "Colonoscopy is due, last done in twenty twenty-two"
6. Review quality measures: Verify that documentation supports measure compliance

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Internal Medicine Documentation

Telehealth has become integral to internal medicine practice for chronic disease management, medication management, and follow-up care. Per CMS 2026 guidelines, specific documentation requirements apply.

Telehealth-Appropriate Internal Medicine Services

1. Chronic Care Management (CCM):

   • Monthly check-ins for chronic disease patients
   • Medication management and adjustments
   • Care coordination activities
   • Requires 20+ minutes of clinical staff time per month

2. Annual Wellness Visit (AWV):

   • Can be conducted via telehealth with modifications
   • Health risk assessment
   • Preventive care planning
   • Advanced care planning discussions

3. Chronic Disease Follow-Up:

   • Diabetes follow-up with home glucose data review
   • Hypertension management with home BP monitoring
   • Medication adjustment visits

4. Remote Patient Monitoring (RPM):

   • Blood glucose monitoring data
   • Blood pressure monitoring data
   • Weight monitoring for CHF patients

Telehealth Documentation Requirements

For virtual internal medicine visits, document:

1. Visit logistics:

   • Platform used (HIPAA-compliant)
   • Patient and provider locations
   • Consent for telehealth services
   • Audio/video quality

2. Modified examination:

   • What could be assessed virtually
   • Patient self-reported findings
   • Home device data (BP, glucose, weight)
   • Examination limitations

3. Remote monitoring data integration:

   • Home glucose logs
   • Home BP readings
   • Weight trends

Example Telehealth Chronic Disease Follow-Up

Annual Wellness Visit (Telehealth Version)

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Internal Medicine SOAP Note Templates

Chronic Disease Follow-Up Template

Annual Comprehensive Visit Template

Related Resources

• Cardiology SOAP Notes Guide
• Geriatric Care SOAP Notes Guide
• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Free SOAP Note Templates