What is the proper format for writing SOAP (Subjective, Objective, Assessment, Plan) notes?

Proper Format for Writing SOAP Notes

The SOAP note format should include four distinct sections: Subjective (patient history), Objective (examination findings), Assessment (diagnosis), and Plan (treatment), with each section containing specific components as recommended by medical guidelines. 1

Subjective Section Components

• Document patient demographics and identification information including name, address, and contact information 1
• Record the chief complaint in the patient's own words, followed by a detailed history of present illness (HPI) that includes onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 1
• Include comprehensive medical history covering previous diagnoses, surgeries, hospitalizations, and current medications with dosages 1
• Document social history including smoking status, alcohol use, substance use, occupation, and living situation 1
• Include a systematic review of systems (ROS) organized by body system 1

Objective Section Components

• Record all vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1
• Document physical examination findings relevant to the patient's condition, organized systematically by body system 1
• Include laboratory values, diagnostic test results, and other measurable data 1
• Document imaging study results when applicable 1
• Record vaccination status and immunization history 1

Assessment Section Components

• List primary diagnosis or problems with supporting evidence 1
• Document severity assessment and current status of each identified problem 1
• Include risk assessment for relevant complications or comorbidities 1
• Document disease staging information when applicable 1
• The Assessment section should synthesize information from both Subjective and Objective sections 2

Plan Section Components

• Detail treatment plan including medications with specific dosages, duration, and goals of therapy 1
• Document diagnostic tests ordered with clear rationale 1
• Include referrals to specialists when indicated 1
• Record patient education provided regarding disease management and self-care 1
• Specify follow-up instructions, including timing of next appointment 1
• Include preventive care recommendations 1

Best Practices for SOAP Note Documentation

• Use a structured format with clear headings for each SOAP component to improve clinical decision-making and communication 1
• Keep notes brief and concise, using bullet points to organize information effectively 1
• Use simple, straightforward, and comprehensible language 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
• Document specific details about the patient's comprehension of treatment plans 1
• Include psychosocial concerns and need for support 1

Special Considerations for Specific Clinical Scenarios

• For chronic disease management, include disease-specific metrics and goals 1
• For medication management, document reasons for dose modifications or exceptions from standard regimens 1
• For cancer care, include staging information, treatment regimen details, and goals of therapy 1
• For preventive care visits, document age-appropriate screening recommendations and immunization status 1
• For patients with multiple comorbidities, organize problems by priority with clear assessment and plan for each 1

Educational Benefits of Proper SOAP Documentation

• Interactive teaching methods for SOAP note writing have been shown to improve students' ability to write clinically appropriate notes 3
• Using standardized rubrics for evaluating SOAP notes can improve students' confidence and ability in clinical documentation 4
• The SOAP format has been successfully adapted for other purposes, such as program evaluation in medical education 5