What is the recommended format for documenting patient information using SOAP (Subjective, Objective, Assessment, Plan) notes?

From the Guidelines

The recommended format for documenting patient information using SOAP notes involves a structured approach with four distinct sections: Subjective, Objective, Assessment, and Plan, as encouraged by the Pediatrics journal in 2019 1.

Key Components of SOAP Notes

• The Subjective section documents the patient's reported symptoms, concerns, and medical history in their own words.
• The Objective section records measurable data such as vital signs, physical examination findings, and test results.
• The Assessment section contains the clinical impression, diagnosis or differential diagnoses based on the subjective and objective information.
• The Plan section outlines the treatment strategy, including specific medications with dosages, follow-up instructions, referrals, and patient education.

Importance of Clear Documentation

Clear and concise documentation is essential for effective communication among healthcare providers, ensuring comprehensive care and continuity of treatment decisions. As noted in the Journal of Allergy and Clinical Immunology in 2007, patient information should be accurately documented, including name, date of birth, and relevant medical history 1.

Recent Guidelines and Recommendations

The most recent guideline from the European Journal of Nuclear Medicine and Molecular Imaging in 2025 emphasizes the importance of documenting patient information, including name, birthdate, and relevant medical history, in a clear and concise manner 1. Similarly, the Annals of Internal Medicine in 2015 highlights the need for efficient and effective clinical documentation, avoiding unnecessary clutter and promoting clear communication among healthcare providers 1.

Best Practices for SOAP Notes

• Use clear and professional language, avoiding abbreviations that might be misinterpreted.
• Focus on medically relevant information that supports clinical decision-making and continuity of care.
• Ensure timely completion of notes and avoid redundant information.
• Use a structured approach with clearly labeled sections for Subjective, Objective, Assessment, and Plan.

From the Research

SOAP Note Format

The recommended format for documenting patient information using SOAP (Subjective, Objective, Assessment, Plan) notes includes:

• Subjective: patient's symptoms and medical history
• Objective: physical examination findings and test results
• Assessment: diagnosis and synthesis of information from the Subjective and Objective sections
• Plan: tests and treatments to narrow the differential diagnosis and manage symptoms 2

Key Components of SOAP Notes

The key components of SOAP notes include:

• Completeness: all relevant information should be included
• Appropriateness: information should be relevant to the patient's condition
• Accuracy: information should be correct and up-to-date
• Signature: the note should be signed by the healthcare provider 3

Evolution of SOAP Notes

The traditional SOAP note format has been expanded and modified over time to include additional information, such as:

• Nature of the presenting complaint
• Counseling
• Medical decision-making 4
• Projections of anticipated course events with and without treatment 5

Importance of SOAP Notes

SOAP notes are essential for:

• History taking and physical exam
• Critical documentation details
• Providing a cognitive aid and index to retrieve information for learning from the record 6, 5