What is the proper format for writing a SOAP (Subjective, Objective, Assessment, Plan) note?

How to Write an Effective SOAP Note

The SOAP note format is a structured documentation method that includes four distinct sections: Subjective, Objective, Assessment, and Plan, designed to efficiently convey patient information, clinical reasoning, and treatment decisions.

Components of a SOAP Note

Subjective (S)

• Document information obtained directly from the patient or their caregiver
• Include:
  • Chief complaint (in patient's own words)
  • History of present illness (HPI)
  • Relevant medical history
  • Medications and allergies
  • Review of systems
  • Patient's perspective on their condition
• Avoid including your own interpretations in this section
• Use direct quotes when appropriate to capture the patient's experience

Objective (O)

• Document measurable, observable data
• Include:
  • Vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation)
  • Physical examination findings
  • Laboratory results
  • Diagnostic imaging results
  • Other test results
• Present data in a systematic, organized manner
• Use specific measurements and values rather than vague descriptions
• Avoid subjective language in this section

Assessment (A)

• Synthesize the subjective and objective information
• Include:
  • Primary diagnosis or problem list (numbered or prioritized)
  • Differential diagnoses
  • Clinical reasoning that explains your assessment
  • Severity and status of each condition
  • Risk factors and complications
• Demonstrate your clinical reasoning process
• Connect your assessment directly to findings in the S and O sections

Plan (P)

• Document your treatment strategy and next steps
• Include:
  • Diagnostic tests ordered
  • Medications prescribed (with dosages and instructions)
  • Therapies or procedures planned
  • Patient education provided
  • Referrals made
  • Follow-up instructions
  • Goals of treatment
• Be specific about each intervention and its purpose
• Address each problem identified in the Assessment section

Best Practices for SOAP Note Documentation

Organization and Format

• Use clear headings for each SOAP section
• Number or prioritize problems in Assessment and Plan sections
• Maintain consistent formatting throughout
• Use standardized terminology and avoid excessive abbreviations 1
• Focus on brevity and thoughtfulness when documenting patient information 1

Content Quality

• Be concise but thorough
• Include only relevant information
• Use objective language in the Objective section
• Ensure your Assessment demonstrates clinical reasoning
• Provide specific details in your Plan
• Document patient education and follow-up instructions

Common Pitfalls to Avoid

• Copying and pasting from previous notes (creates long, verbose, repetitive documentation) 1
• Using subjective language in the Objective section
• Providing vague assessments without supporting evidence
• Creating inadequate plans without specific details
• Delayed documentation (which can lead to errors)
• Excessive use of abbreviations that may be misinterpreted 1

Example SOAP Note Template

SOAP NOTE

Date: [Date]
Time: [Time]
Provider: [Name and Credentials]

S: [Chief complaint in patient's words]
   [History of present illness]
   [Relevant past medical history]
   [Current medications]
   [Allergies]
   [Review of systems]

O: [Vital signs]
   [Physical examination findings]
   [Laboratory results]
   [Diagnostic test results]

A: Problem #1: [Diagnosis/Problem]
   - [Supporting evidence and clinical reasoning]
   - [Severity and status]
   
   Problem #2: [Diagnosis/Problem]
   - [Supporting evidence and clinical reasoning]
   - [Severity and status]

P: Problem #1:
   - [Diagnostic tests]
   - [Medications with dosage and instructions]
   - [Therapies/procedures]
   - [Patient education]
   - [Follow-up]
   
   Problem #2:
   - [Diagnostic tests]
   - [Medications with dosage and instructions]
   - [Therapies/procedures]
   - [Patient education]
   - [Follow-up]

Documentation Considerations for Special Situations

Chronic Disease Management

• Document progress toward treatment goals
• Note medication compliance and side effects
• Update risk factors and complication status 1

Mental Health Assessment

• Include comprehensive mental status examination
• Document thought process, mood, cognitive function, and insight level 1

Procedural Documentation

• For patients receiving sedation or procedures, include:
  • Pre-procedure assessment
  • Monitoring of vital signs during the procedure
  • Post-procedure assessment until discharge criteria are met 1

By following this structured approach to SOAP note documentation, you will create clear, concise, and effective medical records that support quality patient care and facilitate communication among healthcare providers.