SOAP Note Charting Format in Patient Care
The standard format for SOAP note charting in patient care consists of four distinct sections: Subjective, Objective, Assessment, and Plan, with Assessment and Plan placed at the top for improved efficiency and readability. 1
SOAP Note Structure
S - Subjective
- Patient's symptoms, complaints, and history in their own words
- Chief complaint and history of present illness
- Relevant past medical history, medications, allergies
- Review of systems
- Social and family history relevant to current complaint
O - Objective
- Vital signs (temperature, blood pressure, pulse, respiratory rate, oxygen saturation)
- Physical examination findings
- Laboratory results
- Diagnostic imaging results
- Other test results
A - Assessment
- Diagnosis or differential diagnoses
- Clinical reasoning and interpretation of findings
- Synthesis of subjective and objective information
- Risk assessment
P - Plan
- Diagnostic workup (tests ordered)
- Treatment plan (medications, procedures)
- Patient education
- Follow-up instructions
- Consultations or referrals
Best Practices for SOAP Note Documentation
Organization and Format
- Use clear headings for each SOAP component
- Number or prioritize problems in complex cases
- Maintain consistent format throughout documentation
- Use standardized terminology 1
- Sign and date all notes (36.8% of student notes were found to be unsigned in one study) 2
Content Quality
- Ensure accuracy of documented symptoms, physical findings, diagnoses, and plans
- Document physical examination findings under Objective section (not Subjective) 2
- Include all relevant positive and negative findings
- Be specific and avoid vague terminology
- Avoid excessive abbreviations that may cause confusion 1
Efficiency Considerations
- Focus on brevity and thoughtfulness when documenting
- Efficiently convey findings, thought processes, and actions taken
- Avoid copy/paste features that create long, verbose notes
- Recognize that clinical records are exercises in synthesis of information 1
Modern Innovations in SOAP Documentation
APSO Format
Research shows that an APSO format (Assessment and Plan first, followed by Subjective and Objective) may be more efficient than the traditional SOAP format:
- Significantly faster for retrieving information
- Better success rates for finding requested data
- Higher usability ratings from physician users 3
Collapsible Note Design
- Collapsible note designs that emphasize important information and de-emphasize less clinically relevant information have shown improved speed and accuracy
- These designs allow physicians to see more relevant information by showing less at one time 3
Common Documentation Pitfalls to Avoid
- Incomplete documentation
- Subjective language in the objective section
- Vague assessment without clear clinical reasoning
- Inadequate plan without specific actions
- Poor organization that makes information difficult to find
- Excessive abbreviations that may be misinterpreted
- Delayed documentation leading to inaccuracies 1
By following this standardized SOAP note format and incorporating best practices, healthcare providers can create clear, concise, and effective documentation that supports quality patient care and facilitates communication among the healthcare team.