Family medicine visits range from quick sore-throat checks to annual wellness exams with a dozen active problems. A good template handles that range without slowing you down. Below are three visit-type templates you can copy and adjust.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements.
Annual wellness visit template
SUBJECTIVE
Visit type: Annual wellness exam
Patient concerns / health goals: [Patient-stated priorities for the year]
Interval history: [Changes since last annual visit — new diagnoses, hospitalizations, ER visits]
Review of systems: [Comprehensive ROS per visit requirements]
Medications: [Reconciled medication list with doses and adherence notes]
Allergies: [Current allergy list]
Social history:
- Tobacco: [Status, pack-years if applicable]
- Alcohol: [Frequency, quantity]
- Exercise: [Type, frequency]
- Diet: [Notable patterns]
- Safety: [Seatbelt use, firearms in home, fall risk if elderly]
Family history: [Updated family history — new diagnoses in first-degree relatives]
OBJECTIVE
Vital signs: BP ___ | HR ___ | Temp ___ | RR ___ | SpO2 ___ | BMI ___
Physical exam:
- General:
- HEENT:
- Cardiovascular:
- Pulmonary:
- Abdomen:
- Musculoskeletal:
- Neurological:
- Skin:
- Psychiatric (brief screening):
Screening results:
- PHQ-2/PHQ-9: ___
- Alcohol screening (AUDIT-C): ___
- Other age-appropriate screenings: ___
ASSESSMENT
Problem list (active):
1. [Diagnosis #1] — [status: stable / worsening / improved]
2. [Diagnosis #2] — [status]
3. [Diagnosis #3] — [status]
Health maintenance:
- Immunizations due: [List]
- Cancer screenings due: [Colonoscopy, mammogram, Pap, lung CT, etc.]
- Labs due: [Lipid panel, A1c, TSH, etc.]
PLAN
1. [Problem #1]: [Medication changes, referrals, follow-up]
2. [Problem #2]: [Medication changes, referrals, follow-up]
3. [Problem #3]: [Medication changes, referrals, follow-up]
Health maintenance orders:
- Immunizations administered: [List]
- Screenings ordered: [List with timing]
- Labs ordered: [List]
Counseling provided: [Diet, exercise, smoking cessation, fall prevention, etc.]
Follow-up: [Timing for next visit]
Chronic disease follow-up template
SUBJECTIVE
Visit type: Chronic disease follow-up — [Condition(s)]
Interval history: [Symptom changes since last visit]
Medication adherence: [Patient-reported adherence, barriers, side effects]
Home monitoring: [Blood glucose logs, blood pressure readings, peak flow, etc.]
Review of systems: [Focused on relevant systems]
Medications: [Current list with any recent changes]
OBJECTIVE
Vital signs: BP ___ | HR ___ | Weight ___ | BMI ___
Physical exam: [Focused exam relevant to condition(s)]
Recent lab/test results:
- [e.g., A1c: ___ (date)]
- [e.g., Lipid panel: ___ (date)]
- [e.g., eGFR/Cr: ___ (date)]
ASSESSMENT
1. [Chronic condition #1] — [controlled / uncontrolled / at goal / not at goal]
- Current regimen: [Brief summary]
- Trend: [Improving / stable / worsening over past ___ months]
2. [Chronic condition #2] — [same structure]
PLAN
1. [Condition #1]:
- Medication adjustment: [Change or continue]
- Lifestyle modifications discussed: [Specific recommendations]
- Monitoring: [Next labs, home monitoring targets]
- Referral: [If applicable — e.g., diabetes educator, nephrology]
2. [Condition #2]: [Same structure]
Follow-up: [Timing — e.g., 3 months for A1c recheck]
Acute visit template
SUBJECTIVE
Chief complaint: [Patient's stated reason for visit]
History of present illness:
- Onset:
- Duration:
- Severity:
- Associated symptoms:
- Aggravating/relieving factors:
- Prior treatment attempted:
- Exposure history (if infectious concern):
Review of systems: [Focused, pertinent positives and negatives]
Medications: [Current list]
Allergies: [List with reaction type]
OBJECTIVE
Vital signs: BP ___ | HR ___ | Temp ___ | RR ___ | SpO2 ___
Physical exam: [Focused exam — relevant systems only]
Point-of-care testing: [Strep, flu, UA, etc., if performed]
ASSESSMENT
1. [Diagnosis or clinical impression] — [supporting reasoning]
Differential: [If diagnosis uncertain]
PLAN
1. [Diagnosis]:
- Treatment: [Medication with dose, duration, route]
- Patient education: [Warning signs, expected course, self-care]
- Work/school note: [If applicable]
- Follow-up: [Specific timing or criteria — e.g., "return if no improvement in 48 hours"]
Tips for customizing these templates
Layer on complexity when the visit calls for it. A healthy 25-year-old with a sore throat needs a focused acute template. A 65-year-old with diabetes, hypertension, and a new knee complaint needs the multi-problem structure from the chronic disease template plus an acute entry.
Keep your problem list current. Family medicine is longitudinal care — your Assessment section should reflect the patient's full active problem list, not just today's focus. Flag stable problems briefly and give more detail to problems with changes.
Track health maintenance separately. Embedding screening and immunization status inside the Plan section makes it easy to miss items. A dedicated Health Maintenance section (as in the wellness visit template) keeps preventive care visible.
Adapt to your EHR. If your electronic health record has structured fields for immunizations or screenings, use those instead of free text. Reserve the narrative note for clinical reasoning the structured fields cannot capture.
Common family medicine visit types
These templates cover the most frequent encounters, but family medicine is broad. You may also need documentation patterns for:
- Pre-operative clearance — focused history, cardiac risk assessment, medication review
- Sports physicals — standardized screening form plus exam findings
- Pediatric well-child visits — see the pediatrics SOAP note template for developmental milestone tracking
- Mental health visits — when managing anxiety or depression in primary care, consider the psychiatry SOAP note template for mental status exam structure
Learn more about how Dictum supports family medicine documentation with specialty-aware note generation.
Frequently asked questions
How is a family medicine SOAP note different from a general template? Family medicine encounters often cover multiple problems in a single visit, require health maintenance tracking, and include chronic disease management — so the template needs sections for each active problem and preventive care.
What should I include in an annual wellness visit note? Document the health risk assessment, current medications, immunization status, age-appropriate screenings, counseling provided, and an updated problem list. The wellness visit note focuses on prevention rather than acute complaints.
How do I document multiple problems in one visit? Number each problem in the Assessment section and create a matching numbered entry in the Plan. This keeps complex visits organized and supports accurate coding.
Can AI help with family medicine documentation? Yes. Dictum drafts structured SOAP notes from patient encounters or dictation, covering multiple problems and visit types. The clinician reviews and finalizes every note.
Should I use separate templates for different visit types? Many family medicine practices keep a base template and adapt it per visit type — adding a health maintenance section for wellness visits or a more focused HPI for acute complaints.
Spend your time with patients, not paperwork. Try Dictum free — AI-generated SOAP notes drafted from your encounters, ready for review.