What should be included in a SOAP (Subjective, Objective, Assessment, and Plan) note template?

SOAP Note Template Components and Best Practices

A comprehensive SOAP note template should include standardized sections for Subjective, Objective, Assessment, and Plan information, with clear organization of patient data to ensure complete documentation and facilitate clinical decision-making.

Subjective Section Components

• Patient demographics and identification information including name, address, telephone number, and additional contact information 1
• Chief complaint documented in the patient's own words 1
• History of present illness (HPI) with relevant details about onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 1
• Past medical history including previous diagnoses, surgeries, and hospitalizations 2
• Medication history including current medications, dosages, and adherence patterns 2
• Allergies and previous adverse drug reactions 1
• Social history including smoking status, alcohol use, substance use, occupation, and living situation 2
• Family history of relevant medical conditions 2
• Review of systems (ROS) organized by body system 1

Objective Section Components

• Vital signs including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1
• Physical examination findings relevant to the patient's condition, organized by body system 1
• Laboratory values, diagnostic test results, and other measurable data 1
• Imaging study results when applicable 2
• Vaccination status and immunization history 3, 2

Assessment Section Components

• Primary diagnosis or problem list with supporting evidence 1
• Differential diagnoses with clinical reasoning 4
• Severity assessment and current status of each identified problem 3
• Risk assessment for relevant complications or comorbidities 3
• Disease staging information when applicable (e.g., cancer staging) 3

Plan Section Components

• Treatment plan including medications with specific dosages, duration, and goals of therapy 3
• Diagnostic tests ordered with rationale 3
• Referrals to specialists when indicated 2
• Patient education provided regarding disease management and self-care 3
• Follow-up instructions including timing of next appointment 2
• Preventive care recommendations 2

Best Practices for SOAP Note Documentation

• Place the Assessment and Plan sections at the top of the note (APSO format) to improve information retrieval efficiency and clinical workflow 5
• Use a systematic approach to avoid overlooking important elements 1
• Keep documentation simple, straightforward, and comprehensible 1
• Ensure all documented information is factual and objective 1
• Review notes for errors before finalizing 1
• Use appropriate formatting with clear headings and organized structure 1
• Include specific details about patient's comprehension of treatment plans 3
• Document psychosocial concerns and need for support 3
• Regularly review documentation practices to identify areas for improvement 1
• Consider using collapsible sections for less immediately relevant information to improve readability while maintaining comprehensive documentation 5

Special Considerations for Specific Clinical Scenarios

• For chronic disease management, include disease-specific metrics and goals (e.g., A1C targets for diabetes) 3
• For medication management, document reasons for dose modifications or exceptions from standard regimens 3
• For cancer care, include staging information, treatment regimen details, and goals of therapy 3
• For preventive care visits, document age-appropriate screening recommendations and immunization status 3, 2
• For patients with multiple comorbidities, organize problems by priority with clear assessment and plan for each 3

Common Pitfalls to Avoid

• Omitting key elements of the history or physical examination relevant to the presenting problem 4
• Failing to document diagnostic reasoning or differential diagnoses 4
• Neglecting to record patient education or counseling provided 6
• Using vague or subjective language without supporting objective findings 1
• Overlooking documentation of medical decision-making complexity 6
• Failing to link the assessment with the corresponding plan elements 7
• Not documenting patient's response to previous treatments 4