The Quick Guide to Internal Medicine SOAP Note Examples for Healthcare Providers

If you've ever struggled to document complex internal medicine patients in a way that captures multiple comorbidities while meeting insurance requirements, this guide is for you.

I've talked to countless internists and primary care physicians who spend hours after clinic trying to document patients with diabetes, hypertension, hyperlipidemia, and three other chronic conditions—all while justifying medication changes, specialist referrals, and monitoring tests.

The reality is that internal medicine documentation has specific requirements that go beyond simple note-taking.

Insurance companies want to see clear problem-based assessments, appropriate medication management, evidence of preventive care, and documentation that specialist referrals or tests are medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the heavy lifting of documentation while you focus on managing complex patients.

In this article, I'll show you exactly how to write internal medicine SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for Internal Medicine)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for complex medical patients.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For internal medicine specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of multiple chronic conditions and their current status
• Appropriate medication management and therapy adjustments
• Preventive care measures and screening compliance
• Medical necessity for diagnostic testing and specialist consultations
• Coordination of care across multiple medical problems

SOAP stands for:

• S — Subjective: What the patient reports about symptoms, medication adherence, side effects, functional status, and concerns across all their conditions.
• O — Objective: Your clinical findings including vitals, physical exam, lab results, and any diagnostic studies relevant to their chronic conditions.
• A — Assessment: Your clinical assessment organized by problem, with status of each condition and response to current treatment.
• P — Plan: Your treatment plan for each problem including medication adjustments, lab monitoring, lifestyle modifications, referrals, and follow-up timing.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a comprehensive clinical narrative that justifies ongoing management of complex medical conditions.

How You Can Approach Internal Medicine SOAP Notes

There's no single correct method for writing internal medicine SOAP notes, but some approaches work better than others depending on your practice.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit, often using a problem-based format. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, especially when managing 5-8 chronic conditions per patient, and notes can become inconsistent across different visits.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations about each medical problem, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for in chronic disease management.

How to Make Internal Medicine SOAP Notes Faster

One of the biggest complaints I hear from internists is how documentation eats into their already limited time.

You've just finished a full day seeing 20+ patients, each with multiple chronic conditions requiring medication reconciliation, lab review, and care coordination, and instead of going home, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials for specialty referrals or medication prior authorizations; make them too detailed and you've just added hours to your day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"A1c 7.8%, BP 148/92 on current meds, LDL 145, patient non-adherent to statin, ankle edema improving, creatinine stable at 1.4."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Diabetes and Hypertension Management Visit

Patient: 58-year-old male
Chief Complaint: Follow-up for diabetes and hypertension
Visit: Established patient, chronic disease management

S – Subjective:

Patient returns for routine diabetes and hypertension management. Reports good medication compliance. Checking blood sugars twice daily, fasting readings 140-160 mg/dL, post-meal 180-200 mg/dL. Denies hypoglycemic episodes. Following diabetic diet "most of the time" but admits to eating out frequently. Walking 20-30 minutes 3-4 times per week. No chest pain, palpitations, or dyspnea. Denies visual changes, numbness, or tingling in feet. Occasional nocturia twice per night but no other urinary symptoms. Blood pressure readings at home 135-145/85-90 mmHg.

O – Objective:

Vital Signs: BP 148/92, HR 76, Weight 215 lbs (BMI 31.2), Temperature 98.2°F
General: Overweight, alert and oriented
Cardiovascular: Regular rate and rhythm, no murmurs
Pulmonary: Clear bilaterally
Extremities: No edema, pedal pulses intact, monofilament sensation intact bilaterally
Eyes: Fundoscopic exam shows no retinopathy
Labs (fasting, drawn today): A1c 7.8% (previous 7.5% three months ago), Glucose 155 mg/dL, Creatinine 1.1 mg/dL, eGFR 68 mL/min, Urine microalbumin/creatinine ratio 45 mg/g (normal less than 30), LDL 118 mg/dL, HDL 42 mg/dL, Triglycerides 165 mg/dL

A – Assessment:

1. Type 2 Diabetes Mellitus, uncontrolled. A1c trending upward despite current regimen. Patient has suboptimal dietary adherence. Developing early diabetic nephropathy evidenced by microalbuminuria. No signs of neuropathy or retinopathy at this time.

2. Hypertension, inadequately controlled. Blood pressure above goal of less than 130/80 for diabetic patient. Current single-agent therapy insufficient.

3. Dyslipidemia, at goal. LDL controlled on statin therapy, though HDL remains low.

4. Obesity. BMI 31.2, contributing to insulin resistance and cardiovascular risk.

P – Plan:

Diabetes: Increase metformin to 1000mg BID (from 500mg BID). Add SGLT2 inhibitor (empagliflozin 10mg daily) for additional glucose control and renal protection given microalbuminuria. Referred to diabetes education for dietary counseling and carbohydrate counting. Patient to continue home glucose monitoring. Repeat A1c in 3 months, goal less than 7%.

Hypertension: Add lisinopril 10mg daily for blood pressure control and renal protection. Patient to continue home BP monitoring, bring log to next visit. Recheck BP in 4 weeks.

Nephropathy: Annual urine microalbumin screening shows early diabetic kidney disease. ACE inhibitor (lisinopril) will provide renal protection. Monitor creatinine and potassium in 2 weeks after starting ACE inhibitor.

Preventive Care: Due for annual diabetic foot exam and dilated eye exam—referred to ophthalmology. Up to date on colorectal cancer screening. Recommended flu vaccine today, patient accepted and administered.

Lifestyle: Emphasized importance of dietary adherence and weight loss. Goal 5-10% weight reduction. Encouraged increasing physical activity to 150 minutes weekly. Provided written dietary guidelines.

Follow-up: Return in 3 months for diabetes and hypertension reassessment with repeat A1c and basic metabolic panel. Patient to call with any concerning symptoms or if home BP readings consistently greater than 140/90.

---

Example 2: Annual Wellness Visit with Multiple Chronic Conditions

Patient: 72-year-old female
Chief Complaint: Annual physical examination
Visit: Medicare Annual Wellness Visit

S – Subjective:

Patient presents for annual wellness examination. Generally feels well with no acute complaints. Chronic conditions include hypothyroidism, osteoarthritis, and GERD, all stable on current medications. Takes levothyroxine 75mcg daily, omeprazole 20mg daily, and acetaminophen as needed for joint pain. Denies fatigue, weight changes, or cold intolerance. Reflux symptoms controlled on current PPI. Knee pain manageable, uses acetaminophen 2-3 times weekly. Exercises by walking dog daily for 15-20 minutes. Lives independently, performs all ADLs without assistance. No falls in past year. Denies depression, maintains active social life. Non-smoker, no alcohol use.

O – Objective:

Vital Signs: BP 132/78, HR 72, Weight 148 lbs (stable), BMI 25.8, Temperature 98.4°F
General: Well-appearing, age-appropriate
HEENT: Thyroid non-enlarged, no nodules
Cardiovascular: Regular rate and rhythm, no murmurs
Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no masses
Musculoskeletal: Mild crepitus bilateral knees, no effusion or warmth, FROM of all joints
Neurological: Alert and oriented x3, normal gait, no focal deficits
Skin: No suspicious lesions
Labs (fasting): TSH 2.1 mIU/L (normal), Glucose 98 mg/dL, Creatinine 0.9 mg/dL, Total cholesterol 185 mg/dL, LDL 110 mg/dL, HDL 58 mg/dL

A – Assessment:

1. Hypothyroidism, well-controlled on current levothyroxine dose. TSH within normal range.

2. Osteoarthritis, bilateral knees, stable. Pain adequately managed with conservative measures.

3. GERD, controlled on omeprazole. No breakthrough symptoms.

4. Health maintenance. Patient is up to date on most preventive care. Due for screening mammogram and DEXA scan.

P – Plan:

Hypothyroidism: Continue levothyroxine 75mcg daily. Repeat TSH in 12 months.

Osteoarthritis: Continue conservative management with acetaminophen as needed. Encouraged weight-bearing exercise and stretching. If pain worsens, consider physical therapy or topical NSAIDs.

GERD: Continue omeprazole 20mg daily. Discussed possibility of attempting taper in future given long-term PPI use, but patient prefers to continue given good symptom control.

Preventive Care:

• Ordered screening mammogram (last done 18 months ago)
• Ordered DEXA scan for osteoporosis screening (first-time, age-appropriate)
• Colonoscopy up to date (3 years ago, normal, next due in 7 years)
• Administered flu vaccine and Tdap booster today
• Discussed pneumococcal vaccine series, patient completed
• Recommended fall risk assessment at home, provided handout on fall prevention

Cognitive Assessment: Mini-Cog performed, score 5/5 (normal). No concerns for cognitive impairment.

Advance Directives: Health care proxy and living will on file, reviewed and confirmed current.

Follow-up: Return in 12 months for annual wellness visit or sooner if any new concerns arise. Patient to schedule mammogram and DEXA scan within next 2 months and call with results.

---

Example 3: Complex Patient with Multiple Uncontrolled Conditions

Patient: 65-year-old male
Chief Complaint: Follow-up for multiple medical problems
Visit: Established patient, urgent visit requested by patient

S – Subjective:

Patient presents 2 weeks earlier than scheduled due to worsening symptoms. Reports increased shortness of breath with exertion over past week, now occurs with walking one block. Denies chest pain but notes some lower extremity swelling. Admits to dietary non-adherence, "eating whatever I want" and not checking blood sugars regularly. Missed several doses of medications over past month due to running out early. Sleep quality poor, wakes frequently due to nocturia 4-5 times nightly. Fatigue significant, limiting daily activities. Denies fever, cough, or orthopnea.

O – Objective:

Vital Signs: BP 168/96, HR 88, RR 18, O2 sat 94% on room air, Weight 238 lbs (up 8 lbs from last visit 6 weeks ago)
General: Overweight, appears fatigued
Cardiovascular: Regular rhythm, distant heart sounds, 2+ pitting edema bilateral lower extremities to mid-shin, JVP elevated
Pulmonary: Decreased breath sounds at bases, no crackles
Labs (today): Glucose 285 mg/dL, A1c 9.2%, Creatinine 1.8 mg/dL (baseline 1.4), eGFR 38 mL/min, BNP 420 pg/mL, Potassium 5.2 mEq/L

A – Assessment:

1. Congestive Heart Failure, decompensated. Evidence of volume overload with weight gain, edema, elevated JVP, and elevated BNP. Contributing factors include medication non-adherence and dietary indiscretion.

2. Type 2 Diabetes, uncontrolled. A1c significantly elevated at 9.2%, random glucose greater than 280 mg/dL. Patient non-adherent to checking blood sugars and taking medications consistently.

3. Hypertension, severely uncontrolled. BP 168/96, likely contributing to heart failure decompensation.

4. Chronic Kidney Disease, Stage 3b, worsening. Creatinine increased from baseline, eGFR declining. May be related to heart failure or poorly controlled diabetes and hypertension.

5. Medication non-adherence. Patient reports running out of medications and inconsistent dosing, contributing to all above problems.

P – Plan:

Heart Failure: Increase furosemide to 40mg BID (from 20mg daily) for diuresis. Goal weight loss 5-8 lbs over next week. Strict sodium restriction less than 2g daily and fluid restriction 1.5L daily. Patient to monitor daily weights. If no improvement in 3-4 days, may need urgent cardiology consultation or admission for IV diuresis.

Diabetes: Reinforced critical importance of medication adherence. Continue metformin 1000mg BID and insulin glargine 30 units nightly. Patient to resume checking blood sugars twice daily. Social work referral for medication assistance program given financial barriers. Diabetes educator referral for urgent counseling.

Hypertension: Continue lisinopril 40mg daily and carvedilol 25mg BID. Recheck BP in 1 week, goal less than 130/80.

Chronic Kidney Disease: Hold metformin if creatinine continues to rise. Recheck BMP in 3-4 days to monitor renal function and potassium (currently borderline elevated). Avoid nephrotoxic agents.

Medication Adherence: Connected patient with pharmacy assistance program and provided 90-day samples of critical medications to bridge gap. Social work consulted for additional resources. Emphasized that medication non-adherence putting him at risk for hospitalization, dialysis, or worse outcomes.

Follow-up: Return in 1 week for reassessment of heart failure symptoms, weight, and blood pressure. Recheck labs in 3-4 days. Patient given explicit instructions to call or go to ED if worsening dyspnea, chest pain, or inability to manage at home. Discussed that hospitalization may be necessary if outpatient management fails.

---

Key Components Insurance Companies Look For in Internal Medicine SOAP Notes

When reviewing your internal medicine documentation, insurance companies specifically want to see:

1. Problem-Based Assessment

Organize assessment and plan by specific problems rather than body systems. This demonstrates you're addressing each diagnosis appropriately.

2. Medication Management Documentation

Document current medications, any changes made, rationale for adjustments, and monitoring plans for new or adjusted therapies.

3. Chronic Disease Control Metrics

Include objective measures: A1c for diabetes, BP readings for hypertension, LDL for hyperlipidemia. Show trends compared to previous visits.

4. Preventive Care Documentation

Document screenings performed or due, immunizations given, and age-appropriate health maintenance.

5. Specialist Referral Justification

When referring to specialists, document specific clinical reasoning and what you need the specialist to evaluate or manage.

6. Patient Education and Adherence

Document counseling provided on lifestyle modifications, medication adherence, disease management, and any barriers to care identified.

Common Mistakes to Avoid

Undifferentiated Problem Lists: Don't lump everything into "multiple medical problems." Address each condition specifically with its own assessment and plan.

Missing Medication Reconciliation: Always review and document current medications, especially when making changes or adding new therapies.

No Comparison to Baseline: Show trends in lab values, vital signs, and symptoms compared to previous visits to demonstrate disease progression or improvement.

Inadequate Justification for Tests: When ordering labs or imaging, document the clinical indication and how results will change management.

Forgetting Health Maintenance: Insurance tracks preventive care metrics. Document what's been done and what's due.

Vague Follow-Up Plans: Specify when to return, what will be reassessed, and under what circumstances patient should seek care sooner.

Final Thoughts

Internal medicine SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent managing complex medical conditions and coordinating care than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

---

Ready to simplify your internal medicine documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.