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...Name and mr or unique clinic id clinical soap note format subjective the history section hpi include symptom dimensions chronological narrative of patient s complains information obtained from other sources always identify source if not pertinent past medical review systems for example has had any stiffness loss motion joints current medications list with daily dosages objective physical exam laboratory data vital signs including oxygen saturation when indicated focuses all labs x rays etc completed at visit facts that can be verified swelling discoloration outside notes assessment problem your problems a one sentence description major numerical identified listed need to supported by findings in areas above try take highest level diagnosis you low back sprain caused radiculitis involving left th ls nerve root provide least differential diagnoses new east asian western plan based on ve develop diagnostic treatment each may tests procedures studies consultations should education pharmaco...