SOAP Note Example for a Type 2 Diabetes Follow-Up Visit

Q: What goes in the Subjective for a diabetes follow-up?

The Subjective captures the patient's own report since the last visit. Keep it focused on glycemic control, symptoms, side effects, and barriers to adherence rather than a full review of systems. Interval glucose history — home fingerstick or CGM trends, hypoglycemia episodes, and timing. Medication adherence — whether

Q: What belongs in the Objective section?

The Objective records measurable data: vitals, weight and BMI, a directed exam, and labs. For diabetes the most important value is the current A1c , alongside blood pressure and a foot exam. Vitals — BP, heart rate, weight, BMI. Exam — diabetic foot check (pulses, monofilament sensation, skin), and relevant cardiopulmo

Q: How do you write the Assessment for type 2 diabetes?

The Assessment is a one-line clinical judgment: name the condition, state whether it is controlled or uncontrolled relative to the patient's individualized target, and list comorbidities and complication status. A common goal is an A1c below 7% for many non-pregnant adults, but targets should be individualized for age,

Q: What is a complete SOAP note example for a type 2 diabetes follow-up visit?

Below is an original, realistic SOAP note example for a type 2 diabetes follow-up visit . Values are illustrative; adapt them to your patient and local guidelines. S: 58 y/o male with T2DM (dx 2019) here for 3-month follow-up. Reports good adherence to metformin 1000 mg BID; no missed doses. Home fasting glucose log 11

Q: How is a follow-up SOAP note different from the initial diabetes visit?

A follow-up note is interval-focused : it compares today against the last visit rather than re-establishing the full history. Emphasize the trend (for example, A1c moving from 8.1% to 7.4%), the response to prior plan changes, and the next adjustment. The initial visit, by contrast, documents diagnosis, baseline compli

By Raj Lakhani, Founder · Updated June 2026

A SOAP note example for a type 2 diabetes follow-up visit documents the patient's interval glycemic history and adherence (Subjective), focused exam and labs such as the latest A1c (Objective), a status statement on whether diabetes is controlled with complication screening (Assessment), and concrete medication, monitoring, and follow-up steps (Plan). The note below shows each section filled in with specific, realistic values you can adapt to your own patient.

What goes in the Subjective for a diabetes follow-up?

The Subjective captures the patient's own report since the last visit. Keep it focused on glycemic control, symptoms, side effects, and barriers to adherence rather than a full review of systems.

Interval glucose history — home fingerstick or CGM trends, hypoglycemia episodes, and timing.
Medication adherence — whether the patient is taking metformin, GLP-1, SGLT2, or insulin as prescribed, and any missed doses.
Symptoms — polyuria, polydipsia, blurred vision, numbness or tingling, foot problems, GI side effects.
Lifestyle — diet, physical activity, and any new stressors that affect control.

What belongs in the Objective section?

The Objective records measurable data: vitals, weight and BMI, a directed exam, and labs. For diabetes the most important value is the current A1c, alongside blood pressure and a foot exam.

Vitals — BP, heart rate, weight, BMI.
Exam — diabetic foot check (pulses, monofilament sensation, skin), and relevant cardiopulmonary findings.
Labs — A1c, fasting glucose, lipid panel, basic metabolic panel for renal function, and urine albumin-to-creatinine ratio.

How do you write the Assessment for type 2 diabetes?

The Assessment is a one-line clinical judgment: name the condition, state whether it is controlled or uncontrolled relative to the patient's individualized target, and list comorbidities and complication status. A common goal is an A1c below 7% for many non-pregnant adults, but targets should be individualized for age, comorbidities, and hypoglycemia risk.

What is a complete SOAP note example for a type 2 diabetes follow-up visit?

Below is an original, realistic SOAP note example for a type 2 diabetes follow-up visit. Values are illustrative; adapt them to your patient and local guidelines.

S:
58 y/o male with T2DM (dx 2019) here for 3-month follow-up. Reports good
adherence to metformin 1000 mg BID; no missed doses. Home fasting glucose
log 110-145 mg/dL, no hypoglycemia. Denies polyuria, blurred vision, or
foot numbness. Walking 30 min 4x/week; cut back on sugary drinks.
No GI side effects. No chest pain or claudication.

O:
Vitals: BP 132/78, HR 72, Wt 198 lb (down 4 lb), BMI 30.1
Gen: well-appearing, NAD
Feet: skin intact, no ulcers; DP/PT pulses 2+ bilat; monofilament intact
Labs (today): A1c 7.4% (prior 8.1%), fasting glucose 138 mg/dL,
  eGFR 88, urine ACR 18 mg/g, LDL 96 mg/dL

A:
1. Type 2 diabetes mellitus, improving but above goal (A1c 7.4%, target <7%)
2. Obesity (BMI 30.1)
3. Hypertension, at goal on current therapy
No evidence of nephropathy, neuropathy, or foot complications today.

P:
- Continue metformin 1000 mg BID
- Add empagliflozin 10 mg daily for added glycemic + CV/renal benefit;
  counseled on genitourinary infection signs and hydration
- Continue lifestyle: weight loss goal, dietitian referral placed
- Continue current antihypertensive; statin continued for ASCVD risk
- Annual dilated eye exam ordered; foot exam done today
- Recheck A1c, BMP, and urine ACR in 3 months
- Return in 3 months or sooner if symptomatic hypoglycemia

How is a follow-up SOAP note different from the initial diabetes visit?

A follow-up note is interval-focused: it compares today against the last visit rather than re-establishing the full history. Emphasize the trend (for example, A1c moving from 8.1% to 7.4%), the response to prior plan changes, and the next adjustment. The initial visit, by contrast, documents diagnosis, baseline complications, and the full treatment foundation.

How can you write diabetes SOAP notes faster?

Most clinicians save time by using a consistent template and capturing data once. An AI scribe like Doctor Notes listens to the visit and drafts the Subjective, Objective, Assessment, and Plan for you to review and edit, so the structure and trend language are already in place. You stay the author and sign off, but you skip the blank-page typing.

Frequently asked questions

What A1c target should I document for a type 2 diabetes follow-up?

Many guidelines suggest an A1c below 7% for non-pregnant adults, but targets are individualized. Older patients, those with limited life expectancy, or high hypoglycemia risk may have a looser goal such as below 8%; document the rationale in your Assessment.

Should every diabetes follow-up note include a foot exam?

A comprehensive foot exam is recommended at least annually, and more often for patients with neuropathy, prior ulcers, or deformity. Even when a full exam is not due, a brief visual inspection is worth charting in the Objective section.

What complications should the Assessment screen for?

Address nephropathy (urine albumin-to-creatinine ratio, eGFR), retinopathy (annual dilated eye exam), neuropathy and foot risk, and cardiovascular risk (blood pressure, lipids, statin use). Noting these each visit keeps screening on schedule and supports your coding.