How do you create a SOAP (Subjective, Objective, Assessment, Plan) note for any medical scenario?

Creating a SOAP Note for Medical Scenarios

The most effective way to create a SOAP note is to follow a structured format that includes 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

Structure of a SOAP Note

Subjective (S)

• Document the patient's story in their own words
• Include:
  • Chief complaint (CC) - the primary reason for the visit
  • History of present illness (HPI) - detailed chronological account of the symptoms
  • Review of systems (ROS) - systematic review of body systems
  • Past medical history (PMH) - previous illnesses, surgeries, hospitalizations
  • Medications - current medications including dosage and frequency
  • Allergies - medication and non-medication allergies with reactions
  • Social history - smoking, alcohol, substance use, occupation, living situation
  • Family history - relevant family medical conditions

Key documentation points:

• Use neutral, non-judgmental language free from stigma 1
• Document the patient's symptoms in their own words using quotation marks when appropriate
• Include relevant negatives that help rule out differential diagnoses
• Avoid interrupting patients during history-taking 1

Objective (O)

• Document measurable, observable data
• Include:
  • Vital signs - temperature, pulse, respiratory rate, blood pressure, oxygen saturation
  • Physical examination findings - organized by body systems
  • Laboratory results - relevant to the current visit
  • Imaging results - relevant to the current visit
  • Other diagnostic test results

Key documentation points:

• Use specific, descriptive language when documenting negative physical examinations 1
• Maintain a consistent format with standardized terminology 1
• For pediatric patients, include age, weight, and developmental assessment 2
• Document cardiopulmonary systems assessment including pulse rate and regularity, blood pressure, and auscultation of heart and lungs 2

Assessment (A)

• Synthesize and interpret the subjective and objective data
• Include:
  • Primary diagnosis or problem list
  • Differential diagnoses when appropriate
  • Clinical reasoning that led to the diagnosis
  • Severity and status of each condition (improved, worsened, stable)

Key documentation points:

• Document diagnostic reasoning and differential diagnosis considerations 1
• Use specific diagnostic criteria when applicable
• Prioritize problems based on acuity and clinical importance
• Avoid vague statements and provide clear assessments 1

Plan (P)

• Detail the treatment strategy for each problem identified in the assessment
• Include:
  • Diagnostic plan - additional tests or evaluations needed
  • Therapeutic plan - medications, procedures, therapies
  • Educational plan - patient education provided
  • Follow-up plan - timing and parameters for next visit

Key documentation points:

• Document discussions about treatment options and shared decision-making 1
• Include medication details (name, dose, route, frequency, duration) 2
• Specify parameters that would warrant earlier follow-up 1
• Document patient education provided and their understanding 2

Best Practices for SOAP Note Documentation

1. Prioritize patient care over coding and compliance 1

   • Focus on accurately capturing the patient's story to support ongoing care
   • Avoid excessive documentation at the expense of patient interaction

2. Use structured data appropriately 1

   • Capture structured data only where useful for care delivery or essential for quality assessment
   • Maintain a balance between structured and narrative documentation

3. Maintain patient-centered documentation 1

   • Position the computer screen so the patient can view the record
   • Maintain eye contact with the patient while typing
   • Separate typing and patient interaction when necessary

4. Document medication management thoroughly 2

   • For administered medications, document name, route, site, time, dosage/kg, and effect
   • For prescribed medications, include names, doses, and instructions

5. Include appropriate follow-up plans 1

   • Specify timeframe for next appointment
   • Include parameters that would warrant earlier follow-up

Common Pitfalls to Avoid

1. Incomplete documentation 1

   • Missing key elements of history or physical examination
   • Inadequate documentation of clinical reasoning
   • Absence of clear follow-up plans

2. Judgmental or stigmatizing language 1

   • Using terms that may stigmatize patients
   • Making subjective judgments about patients

3. Copy-and-paste errors 1

   • Perpetuating outdated or incorrect information
   • Creating bloated notes with irrelevant historical data

4. Inadequate attention to patient safety 1

   • Failing to verify patient identity before documentation
   • Incorrect documentation leading to medication errors

5. Excessive focus on documentation requirements 1

   • Prioritizing billing requirements over clinical clarity
   • Creating overly lengthy notes that obscure key information

By following this structured approach to SOAP note documentation, clinicians can create clear, concise, and clinically useful documentation that supports patient care while meeting regulatory requirements. The SOAP format remains the foundation of clinical documentation despite proposals for expanded formats such as SNOCAMP (which adds Nature of complaint, Counseling, and Medical decision-making) 3.