What is the proper structure and content of SOAP (Subjective, Objective, Assessment, Plan) notes?

SOAP Note Structure and Content: Best Practices

The proper structure of SOAP notes includes Subjective, Objective, Assessment, and Plan sections, with each section containing specific components to ensure comprehensive documentation of patient care. 1

Subjective Section

• The subjective section should document the patient's chief complaint in their own words, along with a detailed history of present illness (HPI) that includes onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 2
• Include comprehensive patient demographics and identification information such as name, address, and contact information 2
• Document a thorough medical history including past diagnoses, surgeries, hospitalizations, current medications with dosages, and adherence patterns 2
• Record social history elements including smoking status, alcohol use, substance use, occupation, and living situation 2
• Include a systematic review of systems (ROS) organized by body system 2

Objective Section

• Document all vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 2
• Record physical examination findings relevant to the patient's condition, organized systematically by body system 2
• Include all laboratory values, diagnostic test results, and other measurable data 2
• Document imaging study results when applicable 2
• Record vaccination status and immunization history 2

Assessment Section

• List the primary diagnosis or problem list with supporting evidence 2
• Document severity assessment and current status of each identified problem 2
• Include risk assessment for relevant complications or comorbidities 2
• Document disease staging information when applicable 2
• The assessment section should synthesize information from the subjective and objective sections to demonstrate clinical reasoning 3

Plan Section

• Detail the treatment plan including medications with specific dosages, duration, and goals of therapy 2
• Document diagnostic tests ordered with clear rationale 2
• Include referrals to specialists when indicated 2
• Record patient education provided regarding disease management and self-care 2
• Document follow-up instructions, including timing of next appointment 2
• Include preventive care recommendations 2

Best Practices for Documentation

• Use a structured format with clear headings for each SOAP component to improve clinical decision-making and communication 2
• Keep notes brief and concise, using bullet points to organize information effectively 2
• Use simple, straightforward, and comprehensible language 2
• Ensure all documented information is factual and objective 2
• Review notes for errors before finalizing 2
• Flag important information by bolding or highlighting, and avoid abbreviations that may be misinterpreted 2
• Document specific details about the patient's comprehension of treatment plans 2
• Include psychosocial concerns and need for support 2

Format Considerations

• The American Academy of Pediatrics encourages documentation in the SOAP note format to capture a patient's initial visit and monitor progress during follow-up care 1
• Some clinicians prefer an APSO format (Assessment, Plan, Subjective, Objective) which has been shown to be faster and more accurate for finding key information needed for ambulatory chronic disease care 4
• Consider using bullet points rather than narrative paragraphs to improve readability 2
• Avoid field-specific or technical jargon to ensure clear communication among healthcare providers 2

Special Considerations for Specific Clinical Scenarios

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

Common Pitfalls to Avoid

• Avoid cluttered documentation that may increase cognitive load and obscure high-value information 4
• Don't use abbreviations that could be misinterpreted by other healthcare providers 2
• Avoid copying and pasting from previous notes without updating relevant information 2
• Don't include subjective judgments or non-factual statements 2
• Ensure consistency between the assessment and plan sections, as they should have a logical relationship 3