From the Guidelines
A SOAP note should include four essential components: Subjective, Objective, Assessment, and Plan, as recommended by the most recent and highest quality study 1.
Key Components of a SOAP Note
The following are the key components of a SOAP note:
- Subjective: documents the patient's reported symptoms, concerns, and history in their own words, including the chief complaint, history of present illness, and relevant medical history.
- Objective: contains measurable, observable data such as vital signs, physical examination findings, laboratory results, and imaging studies.
- Assessment: presents the healthcare provider's analysis and interpretation of the patient's condition, including diagnoses or differential diagnoses with clinical reasoning.
- Plan: outlines the treatment strategy, including medications with specific names, doses, and durations; ordered tests or referrals; patient education provided; and follow-up instructions.
Importance of a SOAP Note
A SOAP note is essential for comprehensive documentation of patient encounters, facilitating clear communication among healthcare providers, supporting clinical decision-making, and meeting legal and billing requirements while providing a chronological record of the patient's care 1. Additionally, it helps in monitoring and managing patient care, as seen in guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures 1.
Additional Information
Other studies, such as the Canadian stroke best practice recommendations for acute stroke management 1 and allergen immunotherapy: a practice parameter second update 1, provide additional information on the importance of documentation in patient care, but the most recent and highest quality study 1 provides the most relevant guidance on the components of a SOAP note.
Patient Information
Patient information, such as name, date of birth, and health card number, may be included in the SOAP note, but this should be done in accordance with local regulations and guidelines, as noted in the Canadian stroke best practice recommendations 1 and guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
SOAP Note Components
A SOAP note for a patient should include the following components:
- Subjective: This section includes the patient's reported symptoms, medical history, and other relevant information 2, 3, 4
- Objective: This section includes the physician's observations, laboratory results, and other objective data 2, 3, 4
- Assessment: This section synthesizes the information from the Subjective and Objective sections to identify the patient's problems or symptoms 2, 3, 5
- Plan: This section documents the tests, treatments, and other interventions planned to address the patient's problems or symptoms 2, 3, 5, 4
Additional Elements
Some studies suggest including additional elements in the SOAP note, such as:
- Nature of the presenting complaint 3
- Counseling 3
- Medical decision-making 3
- Goals 5
- Rationale 5
- Education 5
- Follow-up 5
Variations in SOAP Note Evaluation
There is variation in how SOAP notes are evaluated, with different tools and methods used to assess the quality of the note 5. Some studies have developed new formats, such as the SNOCAMP note, which expands on the traditional SOAP format 3. Others have repurposed the SOAP note for programme evaluation, such as the Programme Evaluation SOAP Note 6.