Proper Structure for Writing SOAP Notes
The proper structure for writing SOAP notes follows the SOAP format: Subjective, Objective, Assessment, and Plan sections, with each section containing specific clinical information that supports patient care and improves clinical outcomes through enhanced communication. 1
SOAP Note Components
Subjective (S)
- Patient's chief complaint in their own words
- History of present illness
- Relevant medical history, including:
- Past medical history
- Surgical history
- Medication history (including allergies)
- Family history
- Social history
- Review of systems
- History of any seizure disorder
- Summary of previous relevant hospitalizations
- History of sedation or general anesthesia and any complications
- Relevant family history, particularly related to anesthesia 2
Objective (O)
- Vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, temperature)
- Physical examination findings with focus on relevant systems
- Laboratory and diagnostic test results
- Imaging results
- Physical status evaluation (e.g., ASA classification for procedural notes)
- For hospitalized patients, reference to current hospital record 2
Assessment (A)
- Synthesis of information from Subjective and Objective sections
- Primary diagnosis or problem list
- Differential diagnoses
- Clinical reasoning and interpretation of findings
- Evaluation of patient's condition and progress
- Risk assessment 1, 3
Plan (P)
- Treatment plan for each identified problem
- Medications prescribed (including name, dose, route, frequency)
- Diagnostic tests ordered
- Consultations requested
- Patient education provided
- Follow-up instructions with specific timeframe
- Parameters for earlier follow-up 2, 1
Documentation Best Practices
General Documentation Principles
- Use problem-oriented approach to improve decision-making and treatment planning
- Document in chronological order
- Be specific and descriptive, avoiding vague statements
- Use standardized terminology
- Include time-based records for procedures (e.g., medication administration)
- Document adverse events and their treatment 2, 1
For Procedural SOAP Notes
- Document time and condition of patient at discharge
- Include verification that patient's level of consciousness and vital signs have returned to safe levels
- For sedation procedures, document:
- Name, route, site, time, dosage/kg, and effect of administered drugs
- Monitoring parameters during and after procedure
- Time-out verification (patient name, procedure, laterality/site) 2
For Camp Health Documentation
- Document all illnesses and injuries for campers and staff
- Follow state or local licensing requirements
- Monitor progress during follow-up care 2
Common Pitfalls to Avoid
Incomplete documentation
- Missing follow-up plans
- Lack of specific timeframes for next appointments
- Omitting parameters for earlier follow-up 1
Inappropriate language
- Using judgmental or stigmatizing language
- Including subjective judgments 1
Poor organization
Inadequate specificity
- Using vague statements for negative findings
- Lack of detailed descriptions 1
Overuse of copy-paste functionality
- Not reviewing previously documented information before incorporating it
- Propagating outdated or incorrect information 1
Enhancing SOAP Note Quality
- Use appropriate templates to improve completeness and efficiency
- Capture structured data where useful for care delivery
- Document discussions about treatment options and shared decision-making
- Engage in ongoing documentation training
- Use specific, descriptive language when documenting negative findings
- Maintain consistent format with standardized terminology 1, 5
By following this structured approach to SOAP note writing, healthcare providers can ensure comprehensive documentation that facilitates effective communication among the healthcare team, supports clinical decision-making, and ultimately improves patient care outcomes.