What is the proper way to fill out a SOAP (Subjective, Objective, Assessment, Plan) note?

Proper Structure and Components of a SOAP Note

A comprehensive SOAP note must include four distinct sections—Subjective, Objective, Assessment, and Plan—with each section containing specific elements to ensure complete and accurate documentation of patient care. 1

Subjective Section

The Subjective section should document:

• Patient's chief complaint in their own words
• History of present illness (HPI) with chronological narrative
• Relevant past medical history
• Current medications and allergies
• Review of systems related to the complaint
• Psychosocial concerns and support needs
• Patient's understanding of their condition and self-care abilities

Best Practices for Subjective Documentation

• Use direct patient quotes when possible
• Document chronologically with clear timeline
• Include pertinent positives and negatives
• Avoid medical jargon when documenting patient statements
• Document patient's comprehension of medication regimens 2

Objective Section

The Objective section must include:

• Vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation)
• Focused physical examination findings relevant to the complaint
• Laboratory and diagnostic test results
• Imaging findings
• Medication administration records (if applicable)
• Observation of patient behaviors or appearance

Best Practices for Objective Documentation

• Use quantitative measurements whenever possible
• Document only factual, observable data
• Avoid subjective interpretations in this section
• Include all relevant physical examination findings
• Document pre-procedure assessment for procedures 1

Assessment Section

The Assessment section should contain:

• Primary diagnosis or problem identification
• Differential diagnoses when appropriate
• Clinical reasoning supporting the diagnosis
• Disease staging or current status
• Risk assessment
• Severity assessment

Best Practices for Assessment Documentation

• List problems in order of priority
• Include clinical reasoning that connects subjective and objective data
• Document both confirmed and suspected diagnoses
• Include rationale for diagnosis 3
• Synthesize information from Subjective and Objective sections 4

Plan Section

The Plan section must document:

• Diagnostic plans (tests ordered)
• Treatment plans (medications, procedures)
• Patient education provided
• Consultations or referrals
• Follow-up instructions and timeline
• Goals of therapy
• Contingency plans

Best Practices for Plan Documentation

• Document both drug and non-drug therapy 3
• Include patient education details
• Specify follow-up timing and parameters
• Document goals of therapy
• Include rationale for treatment decisions 3

General Documentation Standards

• Sign and date all documentation
• Use clear headings for each SOAP section
• Maintain consistent formatting
• Use standardized terminology
• Avoid excessive abbreviations
• Document in a timely manner
• Ensure documentation reflects actual care provided
• Include time stamps for critical events

Common Pitfalls to Avoid

• Unsigned notes (36.8% of student notes in one study) 5
• Documenting physical examination findings under Subjective section 5
• Omitting non-drug therapy in Plan section (67% omission rate in one study) 3
• Incomplete documentation of physical examination findings 5
• Excessive copy/paste creating verbose notes 1
• Poor organization without clear section delineation 1
• Delayed documentation 1
• Using subjective language in the Objective section 1

Implementation Tips

• Use templates to ensure completeness
• Implement structured data entry when possible
• Develop a consistent documentation workflow
• Review notes for completeness before finalizing
• Consider using expanded formats like SNOCAMP (Subjective, Nature of complaint, Objective, Assessment, Counseling, Medical decision-making, Plan) for complex cases 6
• Ensure documentation meets regulatory and billing requirements

By following these guidelines, clinicians can create SOAP notes that effectively communicate patient care, support clinical decision-making, and meet documentation requirements for quality care and appropriate reimbursement.