How do I complete a SOAP note?

How to Complete a SOAP Note

A SOAP note should document patient information in a structured format including Subjective, Objective, Assessment, and Plan sections, with each section containing specific clinical information to ensure comprehensive documentation of patient care.

Essential Components of SOAP Notes

Subjective (S)

• Document the patient's symptoms, concerns, and history as reported by the patient or family members 1
• Include detailed information about:
  • Onset and progression of symptoms 1
  • Previous medical problems and hospitalizations 1
  • Medication history (prescription, over-the-counter, herbal supplements) 1
  • Allergies and previous adverse drug reactions 1
  • Relevant family history 1
  • For specific conditions, document prodromal symptoms (e.g., fever, malaise) 1

Objective (O)

• Document physical examination findings and measurable data 1
• Include:
  • Vital signs (heart rate, blood pressure, respiratory rate, temperature, oxygen saturation) 1, 2
  • Physical examination findings relevant to the patient's condition 2
  • Results of any diagnostic tests performed 1
  • Document if vital signs cannot be obtained due to patient non-cooperation 1, 2
  • Patient demographics (age, weight) 1, 2

Assessment (A)

• Formulate and document your clinical impression of the patient's condition 1
• Include:
  • Diagnosis or differential diagnoses 1
  • Clinical reasoning supporting your assessment 1
  • Severity assessment when applicable 1
  • Physical status evaluation (e.g., ASA classification for procedural cases) 1, 2

Plan (P)

• Document the treatment plan and next steps 1
• Include:
  • Diagnostic workup plans 1
  • Treatment recommendations 1
  • Patient education provided 1
  • Follow-up instructions 1
  • Referrals if needed 1
  • Medications prescribed with dosage, route, and frequency 1

Best Practices for SOAP Note Documentation

General Documentation Guidelines

• Sign and date all notes 3
• Use clear, concise language avoiding unnecessary abbreviations 1
• Document in chronological order 1
• Include time-based records for procedures (medication administration, monitoring) 1
• Document adverse events and their treatment 1

Common Pitfalls to Avoid

• Failing to sign or date notes 3
• Documenting subjective information in the objective section 3
• Omitting critical information about allergies or medication history 2
• Inadequate documentation of physical examination findings 3
• Failing to document patient education provided 1
• Not documenting when vital signs cannot be obtained 2

Special Considerations

• For procedural documentation, include "time out" confirmation of patient name, procedure, and site 1
• For discharge documentation, include the patient's condition and that consciousness and vital signs have returned to baseline 1
• For patients with chronic conditions, document progress against previous visits 1
• Include the name of the patient's primary care provider or medical home 2

Quality Improvement in Documentation

• Review notes regularly for completeness and accuracy 1
• Track adverse events for quality improvement purposes 1
• Use standardized formats to ensure consistency 4
• Consider using electronic health record templates while maintaining narrative quality 1

Practical Implementation Tips

• Use the SOAPME acronym as a checklist for procedural documentation: Suction, Oxygen, Airway equipment, Pharmacy, Monitors, Equipment 1
• Document the extent of physical findings on body maps or diagrams when applicable 1
• Include patient-reported health status, functional status, and quality of life 2
• Maintain focus on the narrative quality of notes while meeting documentation requirements 1

By following these guidelines, you can create comprehensive SOAP notes that effectively communicate patient information, support clinical decision-making, and meet documentation requirements for healthcare settings.