How to Write a SOAP Note
The proper format for writing a SOAP note includes four distinct sections: Subjective, Objective, Assessment, and Plan, with each section containing specific information to efficiently document patient care. 1
Subjective Section
- Document the patient's history and complaints in their own words
- Include:
- Chief complaint (CC)
- History of present illness (HPI)
- Past medical history (PMH)
- Medications and allergies
- Family history
- Social history
- Review of systems (ROS)
Objective Section
- Document factual, measurable data that you observe or collect
- Include:
- Vital signs (temperature, blood pressure, pulse, respiratory rate)
- Physical examination findings organized by body system
- Laboratory values
- Diagnostic imaging results
- Other test results
Assessment Section
- Synthesize information from the Subjective and Objective sections
- Include:
- Primary diagnosis or problem list (numbered or prioritized)
- Differential diagnoses
- Clinical reasoning and rationale for diagnoses
- Status of existing conditions (improved, worsened, stable)
Plan Section
- Document the treatment strategy for each problem identified
- Include:
- Diagnostic tests ordered
- Medications prescribed (including dose, route, frequency)
- Therapies or procedures
- Patient education provided
- Consultations or referrals
- Follow-up instructions and timeline
Best Practices for SOAP Notes
- Use clear headings for each section to maintain organization 1
- Number or prioritize problems in the Assessment and Plan sections
- Maintain a consistent format throughout your documentation
- Use standardized terminology and avoid excessive abbreviations
- Be concise but thorough - focus on brevity and thoughtfulness
- Document in a timely manner to ensure accuracy
- Include your signature and credentials
Common Pitfalls to Avoid
- Incomplete documentation in any section
- Using subjective language in the Objective section
- Vague assessment without clear clinical reasoning
- Inadequate plan that doesn't address all problems
- Poor organization making it difficult to follow
- Excessive abbreviations that may be misinterpreted
- Delayed documentation leading to inaccuracies 1
- Copy/pasting that creates long, verbose, and repetitive notes 1
Special Considerations
- For patients with chronic conditions, document progress toward treatment goals, medication compliance, side effects, and updates to risk factors 1
- For patients receiving procedures, include pre-procedure assessment, monitoring during the procedure, and post-procedure assessment 1
- For mental health evaluations, include assessment of thought process, mood, cognitive function, and insight level 1
Remember that SOAP notes are exercises in synthesis of information over time and should efficiently convey your findings, thought processes, decisions, and actions taken 1.