How do I write a SOAP report?

How to Write a SOAP Report

The SOAP format is the standard structure for medical documentation, consisting of Subjective, Objective, Assessment, and Plan sections that provide a clear and comprehensive clinical record. 1

General Structure and Components

1. Demographics

• Patient name, identification number/date of birth, gender
• Site administrative data and contact information
• Date of the visit/encounter

2. Subjective (S)

• Document the patient's reported symptoms and concerns in their own words
• Include relevant medical history related to the current complaint
• Document duration and progression of symptoms
• Avoid protective expressions (e.g., "is likely," "cannot be excluded") unless there is relevant doubt 1
• Use quantified data rather than qualitative descriptions when possible

3. Objective (O)

• Vital signs and measurements
• Physical examination findings focused on the problem
• Laboratory and diagnostic test results
• Document all physical findings systematically by body system
• Record physical examination focused on the problem of the visit 2
• Use precise, quantitative descriptions rather than vague terms like "small," "medium," or "large" 1

4. Assessment (A)

• Primary diagnosis or differential diagnoses
• Clinical reasoning/differential diagnostic notes 2
• Interpretation of findings from S and O sections
• Assessment of disease severity or stage
• Risk factors and complications
• Clearly state if findings are compatible with a specific diagnosis 1

5. Plan (P)

• Diagnostic plan: additional tests or investigations needed
• Treatment plan: medications, procedures, interventions
• Patient education and counseling provided
• Follow-up instructions and timeline
• Referrals to specialists if needed
• Negotiation of aims to achieve with the patient 2

Best Practices for SOAP Documentation

Clarity and Precision

• Use standardized terminology recognized in both general medicine and specialty areas 1
• Replace qualitative descriptions with quantified data whenever possible
• Document relevant findings even if normal or negative
• Avoid abbreviations that could be misinterpreted

Completeness

• Sign and date all documentation 3
• Include all pertinent positive and negative findings
• Document any counseling or education provided to the patient
• Record the patient's response to interventions

Organization

• Follow the SOAP structure consistently
• Use appropriate headings for each section
• Present information in a logical sequence
• Use bullet points for clarity when appropriate

Common Pitfalls to Avoid

1. Incomplete documentation: Missing signatures, incomplete physical examination findings, or omitted plan elements 3

2. Inappropriate section content: Documenting symptoms under Objective instead of Subjective section 3

3. Vague terminology: Using qualitative terms instead of specific measurements 1

4. Poor diagnostic reasoning: Failing to document clinical reasoning in the Assessment section 2

5. Inadequate plan: Not including specific follow-up instructions or patient education details

6. Excessive use of protective language: Using too many hedging terms that create ambiguity 1

7. Lack of patient-centered goals: Failing to document negotiated goals with the patient 2

Example SOAP Note Format

S (Subjective):

"Patient reports 3 days of productive cough with yellow sputum, fever measured at home as 101.2°F, and increasing shortness of breath. Symptoms began gradually and have worsened despite over-the-counter acetaminophen. No chest pain, no recent travel, no known sick contacts."

O (Objective):

"Vital signs: T 100.8°F, HR 92, RR 20, BP 132/78, O2 sat 94% on room air General: Mild respiratory distress, speaking in full sentences HEENT: Oropharynx clear, no exudates Lungs: Crackles in right lower lobe, no wheezing Heart: Regular rate and rhythm, no murmurs Labs: WBC 12,500 with neutrophil predominance, chest X-ray shows right lower lobe infiltrate"

A (Assessment):

"Community-acquired pneumonia, right lower lobe, moderate severity

• Based on productive cough, fever, and focal lung findings
• CURB-65 score of 1 (age >65)
• Differential includes acute bronchitis, influenza, COVID-19"

P (Plan):

"1. Antibiotics: Amoxicillin-clavulanate 875/125 mg PO BID for 7 days 2. Symptomatic treatment: Acetaminophen 650 mg PO q6h PRN fever/pain 3. COVID-19 and influenza testing completed today 4. Follow-up in 2-3 days for symptom check 5. Return sooner if increased shortness of breath, chest pain, or worsening symptoms 6. Patient educated on importance of completing full antibiotic course"

By following this structured approach to SOAP documentation, you will create clear, comprehensive medical records that facilitate effective clinical decision-making and communication among healthcare providers.