General Surgery SOAP Note Template –Simplify Surgical Care Documentation
SCRIBE AI’s General Surgery Template is designed to support surgeons and care teams throughout the perioperative journey. From pre-op assessments to post-op follow-ups, this template ensures structured SOAP notes that improve accuracy, compliance, and surgical outcomes.
Surgical Team Focused: SOAP notes tailored for general surgery streamline documentation and support better outcomes.
🧾 Why Use a General Surgery SOAP Note Template?
General Surgery SOAP notes are designed for surgery-focused accuracy, efficiency, and compliance—making them essential for modern surgical care documentation.
Surgery-Focused Structure
Capture surgical history, operative notes, and postoperative progress.
Comprehensive Assessments
Document wounds, pain scores, drains, and recovery milestones.
Improved Efficiency
Reduce charting time during high-volume surgical care.
Continuity of Care
Standardized notes enhance communication across surgical teams.
Compliance & Billing Support
Built for surgical coding and regulatory standards.
👩⚕️ Who Can Use This General Surgery Template?
General Surgeons
Surgical Residents & Fellows
Nurse Practitioners in Surgery
Surgical ICUs and Recovery Units
Outpatient & Ambulatory Surgical Centers
🧩 General Surgery SOAP Note Format
This template guides you through each step of surgical SOAP documentation, ensuring all critical details are captured for optimal surgical care and compliance.
1. Subjective (Patient Report)
Record presenting complaints, surgical concerns, and patient-reported outcomes.
What to Include:
- Chief complaint (patient's words)
- Surgical history and concerns
- Pain scores and symptom changes
- Patient-reported outcomes and goals
Example:
"Patient reports abdominal pain improving post-appendectomy but still tender near incision site."
2. Objective (Clinical Findings & Surgical Observations)
Include vitals, wound exam, drains, lab results, and imaging.
What to Include:
- Vital signs (BP, HR, temp, etc.)
- Wound/incision exam
- Drains, tubes, and outputs
- Lab and imaging results
Example:
"BP 132/84 mmHg, afebrile, incision clean and dry, mild erythema noted around wound edges."
3. Assessment (Clinical Impressions)
Summarize surgical outcomes, recovery progress, and risks.
What to Include:
- Surgical outcome and progress
- Complications or risks
- Pain and wound healing status
- Relevant clinical reasoning
Example:
"Postoperative recovery progressing well, mild wound inflammation likely reactive, no signs of infection."
4. Plan (Treatment & Follow-Up)
Outline wound care, pain management, mobility instructions, and follow-up.
What to Include:
- Wound care and dressing changes
- Pain management plan
- Mobility and activity instructions
- Follow-up and monitoring schedule
Example:
"Continue oral antibiotics x5 days, change dressings daily, encourage early ambulation, review in 1 week."
✅Best Practices for General Surgery Documentation
- ✓Always include pre- and post-operative notes for continuity.
- ✓Track pain management and wound healing daily.
- ✓Document operative findings clearly for legal and compliance purposes.
- ✓Standardize follow-up plans for better patient safety.
🛡️Why Choose SCRIBE AI for General Surgery SOAP Notes?
SCRIBE AI’s General Surgery Template reduces documentation burden, ensures compliance, and enhances surgical team communication—helping providers deliver safer, more effective care.
- ✓Save Time
- ✓Improve Accuracy
- ✓Ensure Compliance
- ✓Enhance Surgical Care
Simplify General Surgery Documentation with SCRIBE AI
SCRIBE AI’s General Surgery SOAP template removes guesswork and saves time, making accurate documentation easier than ever. Our smart forms and AI suggestions help you capture what matters—fast.
Conclusion
Master general surgery SOAP notes with SCRIBE AI’s template—save time, improve accuracy, and ensure compliance for every surgical care visit.