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SOAP Pro Template (Enhanced ROS & Physical Exam)

Wesley Combs avatar
Written by Wesley Combs
Updated over a week ago

SOAP Pro Template (Enhanced ROS & Physical Exam)

Article Type: Template Guide
​ Target Audience: Healthcare providers seeking comprehensive documentation
​ Last Updated: January 2026

Overview

The SOAP (ROS & PE enhanced) template, also known as SOAP Pro, is designed for providers who need more detailed documentation of the Review of Systems and Physical Examination components. This template automatically captures and organizes comprehensive ROS and PE findings from your patient conversations.

When to Use SOAP Pro

Ideal For:

  • New patient visits requiring thorough documentation

  • Complex cases with multiple system involvement

  • Specialty consultations needing detailed physical findings

  • Pre-operative assessments requiring complete ROS

  • Insurance/compliance documentation requiring comprehensive notes

Standard SOAP vs SOAP Pro

Feature

Standard SOAP

SOAP Pro

Subjective

✅

✅

Objective

Basic

Enhanced with detailed PE

Assessment

✅

✅

Plan

✅

✅

Review of Systems

Basic mention

Complete 14-system review

Physical Exam

General findings

Structured by system

Template Structure

Subjective

  • Chief Complaint

  • History of Present Illness

  • Past Medical History

  • Medications

  • Allergies

  • Social History

  • Family History

Review of Systems (Enhanced)

Comprehensive documentation across all relevant systems:

System

Examples

Constitutional

Fever, chills, fatigue, weight changes

Eyes

Vision changes, pain, discharge

ENT

Hearing, sore throat, congestion

Cardiovascular

Chest pain, palpitations, edema

Respiratory

Cough, shortness of breath, wheezing

GI

Nausea, vomiting, abdominal pain

GU

Dysuria, frequency, incontinence

Musculoskeletal

Joint pain, weakness, stiffness

Integumentary

Rashes, lesions, changes

Neurological

Headache, dizziness, numbness

Psychiatric

Mood, anxiety, sleep

Endocrine

Thirst, temperature intolerance

Hematologic/Lymphatic

Bleeding, bruising, lymph nodes

Allergic/Immunologic

Allergies, frequent infections

Physical Examination (Enhanced)

Structured findings organized by system:

PHYSICAL EXAMINATION:General: Alert, oriented, no acute distress
Vitals: [If discussed]HEENT:
- Head: Normocephalic, atraumatic
- Eyes: PERRLA, EOM intact
- Ears: TMs clear bilaterally
- Nose: Mucosa pink, no discharge
- Throat: Oropharynx clear, no erythemaNeck: Supple, no lymphadenopathy, no thyromegalyCardiovascular: Regular rate and rhythm, no murmurs/rubs/gallopsRespiratory: Clear to auscultation bilaterally, no wheezes/rhonchi[Additional systems as examined...]

Assessment & Plan

  • Numbered problem list

  • Assessment for each problem

  • Detailed plan including:

  • Medications

  • Tests ordered

  • Referrals

  • Follow-up

How to Select SOAP Pro

From Template Picker

  1. Click on Template dropdown

  2. Under Standard Templates, select SOAP (ROS & PE enhanced)

  3. Begin your encounter

Setting as Default

  1. Go to Settings > Note

  2. Find Default Template

  3. Select SOAP (ROS & PE enhanced)

  4. Save settings

Tips for Best Results

During the Encounter

For Complete ROS:
- Ask about systems even briefly
- Document both positive and negative findings
- "Any chest pain? Shortness of breath?" captures cardiovascular and respiratory

For Detailed PE:
- Verbalize your findings during exam
- State normal and abnormal findings
- "Heart sounds regular, no murmurs" captures exam details

Dictation Tips

DO say:
- "Review of systems is negative for..."
- "On physical exam, the lungs are clear..."
- "Cardiovascular exam reveals..."

Ambient Scribe captures:
- Natural conversation about symptoms
- Physical exam verbalization
- Both positive and pertinent negative findings

Sample Output

# SOAP Note## Subjective### Chief Complaint
Follow-up for hypertension management### History of Present Illness
58-year-old male presents for hypertension follow-up. Patient reports
good compliance with lisinopril 10mg daily. Denies headaches, visual
changes, or chest pain. Home BP readings averaging 138/85...### Review of Systems
- Constitutional: Negative for fever, chills, unintentional weight loss
- Cardiovascular: Negative for chest pain, palpitations, orthopnea
- Respiratory: Negative for dyspnea, cough, wheezing
- Neurological: Negative for headaches, dizziness, focal weakness
- [All other systems reviewed and negative unless noted above]## Objective### Vital Signs
BP: 142/88 | HR: 76 | RR: 16 | Temp: 98.2°F | SpO2: 98% RA### Physical Examination
**General:** Well-appearing male in no acute distress
**HEENT:** Normocephalic, PERRLA, no JVD
**Cardiovascular:** Regular rate and rhythm, S1/S2 normal, no murmurs
**Respiratory:** Clear to auscultation bilaterally
**Extremities:** No lower extremity edema, pulses 2+ bilaterally
**Neurological:** Alert and oriented, cranial nerves intact## Assessment
1. Essential hypertension - not at goal## Plan
1. Increase lisinopril to 20mg daily
2. Continue low sodium diet
3. Home BP monitoring
4. Follow-up in 4 weeks
5. Labs: BMP to check potassium in 2 weeks

Frequently Asked Questions

Q: Is SOAP Pro longer than standard SOAP?
A: Yes, it captures more detail. Use standard SOAP for straightforward visits.

Q: Will it include systems I didn't discuss?
A: Only systems mentioned in the conversation are documented. Ambient Scribe doesn't fabricate findings.

Q: Can I customize the SOAP Pro template?
A: Yes! Create a custom template based on SOAP Pro and modify sections to your preference.

Q: Is SOAP Pro appropriate for all specialties?
A: It's especially useful for primary care, internal medicine, and any specialty requiring comprehensive documentation. Specialists may prefer specialty-specific templates.

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