How to write a patient narrative note in SOAP format?

How to Write a Patient Narrative Note in SOAP Format

The SOAP format is the most effective and standardized approach for documenting patient encounters, consisting of four distinct sections: Subjective, Objective, Assessment, and Plan, each containing specific elements to ensure complete and accurate documentation of patient care. 1

Structure of a SOAP Note

1. Subjective Section

This section documents information provided by the patient or informant.

• Chief Complaint (CC): Brief statement of why the patient is seeking care, in their own words
• History of Present Illness (HPI): Detailed narrative of the current problem
  • Onset, duration, location, quality, severity, timing
  • Alleviating/aggravating factors
  • Associated symptoms
  • Previous treatments and their effects
• Past Medical History: Relevant medical conditions, surgeries, hospitalizations
• Medications: Current medications with dosages and adherence
• Allergies: Medication and other allergies with reactions
• Family History: Relevant family medical conditions
• Social History: Occupation, living situation, habits (smoking, alcohol, drugs)
• Review of Systems (ROS): Systematic review of body systems

2. Objective Section

This section includes measurable, observable data.

• Vital Signs: Temperature, pulse, respiratory rate, blood pressure, oxygen saturation, pain score
• Physical Examination: Organized by body systems
  • Use specific, descriptive language for both positive and negative findings 1
  • Avoid vague statements when documenting negative findings
• Laboratory Results: Relevant test results with reference ranges
• Imaging Studies: Results of any diagnostic imaging
• Other Diagnostic Tests: EKG, pulmonary function tests, etc.

3. Assessment Section

This section synthesizes information from the subjective and objective sections.

• Primary Diagnosis/Problem: Main condition being addressed
• Differential Diagnoses: Alternative explanations for the patient's presentation
• Clinical Reasoning: Explanation of how you arrived at your diagnosis
• Severity Assessment: Evaluation of the condition's severity
• Disease Progression: Status compared to previous visits

4. Plan Section

This section outlines the management strategy.

• Diagnostic Plan: Additional tests or evaluations needed
• Therapeutic Plan: Medications, procedures, therapies
• Educational Plan: Patient education provided
• Follow-up Plan:
  • Specific timeframe for next appointment
  • Parameters for earlier follow-up (e.g., "Return if symptoms worsen") 1
  • Referrals to specialists or other services

Best Practices for SOAP Documentation

1. Maintain Consistency: Use standardized terminology and consistent formatting 1
2. Be Specific: Use quantitative measurements and descriptive language 1, 2
3. Document Thoroughly: Include both positive and negative findings relevant to the case
4. Avoid Judgmental Language: Use objective, non-stigmatizing terminology 1
5. Ensure Clarity: Use clear headings and organized structure 1
6. Include Source Attribution: When documenting information from others, identify the source 1
7. Document Patient Instructions: Record what the patient was told and their understanding 1

Common SOAP Note Formats

Research has identified five common combinations of format for HPI and Assessment/Plan sections 2:

1. Story + List with Categories: Narrative HPI followed by categorized plan (most common in primary care)
2. Story + Story: Narrative format for both sections
3. List without Categories + List with Categories: Bulleted HPI with categorized plan
4. List with Categories + List with Categories: Categorized format for both sections
5. List with Categories + Story: Categorized HPI with narrative plan

Primary care notes tend to have longer HPI and Assessment/Plan sections compared to specialty care notes 2.

Common Pitfalls to Avoid

• Incomplete Documentation: Missing critical elements of history or examination
• Copy-Pasting: Blindly copying previous notes without updating
• Vague Statements: Using non-specific terms like "normal exam" without details
• Missing Follow-up Plans: Failing to document specific follow-up instructions
• Incorrect Patient Information: Verifying patient identity before documentation 1
• Overuse of Templates: Relying too heavily on templates without customization

Sample SOAP Note Template

SUBJECTIVE:
Chief Complaint: "[Patient's exact words]"

HPI: [Age] [gender] with [relevant PMH] presents with [main symptom] for [duration]. 
Symptoms began [onset]. Describes pain as [quality] rated [severity/10]. 
[Aggravating/alleviating factors]. [Associated symptoms]. 
[Previous treatments and response].

PMH: [Relevant past medical history]
Medications: [Current medications with dosages]
Allergies: [Medication allergies and reactions]
FH: [Relevant family history]
SH: [Relevant social history]
ROS: [Pertinent positive and negative findings]

OBJECTIVE:
Vitals: T: [temp] HR: [heart rate] RR: [resp rate] BP: [blood pressure] O2: [oxygen sat] Pain: [pain scale]

Physical Exam:
General: [appearance, distress level]
HEENT: [specific findings]
CV: [specific findings]
Pulm: [specific findings]
Abd: [specific findings]
Ext: [specific findings]
Neuro: [specific findings]

Labs/Studies: [relevant results with reference ranges]

ASSESSMENT:
1. [Primary diagnosis/problem]: [Brief explanation of clinical reasoning]
2. [Secondary diagnosis/problem]: [Brief explanation]
3. [Differential diagnoses to consider]

PLAN:
1. Diagnostics: [Tests ordered with rationale]
2. Therapeutics: [Medications prescribed with dosing]
3. Patient Education: [Information provided to patient]
4. Follow-up: [Specific timeframe and conditions for earlier return]

By following this structured approach to SOAP note documentation, you can ensure comprehensive, clear, and clinically useful patient records that facilitate quality care and effective communication among healthcare providers.