Standard Method for SOAP Note Documentation
The standard method for documenting patient care using SOAP notes requires structured documentation with 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
- Document the patient's history and complaints in their own words when possible
- Include:
- Chief complaint (CC)
- History of present illness (HPI)
- Past medical history (PMH)
- Medications
- Allergies
- Review of systems (ROS)
- Social history
- Family history
- Use direct patient quotes when appropriate
- Document pertinent positives and negatives
- Avoid medical jargon when documenting patient statements 1
Objective Section
- Document only factual, observable data:
- Vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation)
- Physical examination findings relevant to the complaint
- Laboratory values
- Diagnostic imaging results
- Other test results 1
- Use quantitative measurements whenever possible
- For procedures (like sedation), include specific documentation such as ASA classification and airway evaluation 2
- For mental health assessments, include thought process, mood, cognitive function, and insight level 1
Assessment Section
- List problems in order of priority
- Include clinical reasoning that connects subjective and objective data
- Document both confirmed and suspected diagnoses
- For chronic conditions, document progress toward treatment goals and update risk factors and complication status 1
- Include differential diagnoses when appropriate
Plan Section
- Document treatment plans for each problem identified in the assessment
- Include:
- Medications (with dosage, frequency, duration)
- Laboratory or diagnostic tests ordered
- Referrals to specialists
- Patient education provided
- Non-pharmacological interventions
- Follow-up instructions and timing 1
Best Practices for SOAP Note Documentation
- Use clear headings and maintain a consistent format
- Number or prioritize problems
- Use standardized terminology
- Avoid excessive copy/paste that creates verbose notes
- Ensure templates don't compromise the patient narrative
- Document time-based records of all interventions, especially for procedures 2
- For procedures, document monitoring parameters such as level of consciousness, vital signs, and oxygen saturation 2
- Use standardized discharge criteria when applicable 2
Common Pitfalls to Avoid
- Incomplete documentation
- Subjective language in the objective section
- Vague assessments without clear clinical reasoning
- Inadequate plans without specific instructions
- Poor organization and excessive abbreviations
- Delayed documentation 1
- Failure to document patient understanding of instructions 1
Documentation Tools and Implementation
- Standardized forms improve compliance with documentation and reduce adverse events 2
- Electronic health records often include templates for SOAP notes
- Consider using structured assessment tools like the Aldrete scoring system for procedural recovery 2
- Quality improvement processes should include regular review of documentation practices 2
By following this structured approach to SOAP note documentation, healthcare providers can ensure comprehensive, accurate, and consistent patient care records that facilitate communication among the healthcare team and support optimal patient outcomes.