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

SOAP Note Template Components

A comprehensive SOAP note template should include four core sections—Subjective, Objective, Assessment, and Plan—with specific structured elements in each section to ensure complete clinical documentation and support medical decision-making. 1

Subjective Section: What the Patient Reports

The subjective section captures the patient's narrative and should include:

• Patient demographics and identification information including name, address, telephone number, and additional contact information 1
• Chief complaint documented in the patient's own words, followed by a detailed history of present illness (HPI) that specifies onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 1
• Past medical history encompassing previous diagnoses, surgeries, and hospitalizations 1
• Current medications with dosages and adherence patterns to ensure accurate medication reconciliation 1, 2
• Social history including smoking status, alcohol use, substance use, occupation, and living situation 1
• Review of systems (ROS) organized systematically by body system 1

Objective Section: Measurable Clinical Data

This section documents observable and measurable findings:

• 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 and diagnostic test results with all measurable data 1
• Imaging study results when applicable 1
• Vaccination status and immunization history 1, 2
• Height, weight, and BMI calculation for monitoring physical condition 2

Assessment Section: Clinical Synthesis and Reasoning

The assessment synthesizes information from the subjective and objective sections:

• Primary diagnosis or problem list with supporting evidence 1
• Explicit documentation of clinical reasoning that led to the final diagnosis or differential diagnoses 2
• Severity assessment and current status of each identified problem 1
• Risk stratification for relevant conditions and potential complications 1, 2
• Disease staging information when applicable 1
• Documentation of the complexity of medical decision-making based on the number of diagnoses considered, amount/complexity of data reviewed, and risk of complications 2

Plan Section: Treatment and Follow-Up Strategy

The plan section outlines the management approach:

• Treatment plan with medications specifying exact dosages, duration, and goals of therapy 1
• Diagnostic tests ordered with clinical rationale 1, 2
• Referrals to specialists when indicated 1
• Patient education provided regarding disease management and self-care 1
• Action plans based on achievable patient goals with specific, measurable objectives 2
• Medication management plans and lifestyle modification recommendations 2
• Follow-up instructions with specific timeframes for the next appointment 1, 2
• Preventive care recommendations 1
• Issues requiring monitoring before the next visit 2

Documentation Best Practices

Use structured templates with clear headings to improve clinical decision-making and communication 1, 2

• Keep notes brief and concise using bullet points to organize information 1
• Flag important information by bolding or highlighting critical findings 1
• Avoid field-specific jargon and ambiguous abbreviations that may be misinterpreted 1
• Ensure all documented information is factual and objective 1
• Review notes for errors before finalizing 1
• Balance structured data entry with narrative information to capture essential details while minimizing documentation burden 2
• Document shared decision-making with patients to promote patient-centered care 2

Special Clinical Scenario Considerations

For specific clinical contexts, additional elements are necessary:

• Chronic disease management: Include disease-specific metrics and goals 1
• Medication management: Document reasons for dose modifications or exceptions from standard regimens 1
• Cancer care: Include staging information, treatment regimen details, and goals of therapy 1
• Preventive care visits: Document age-appropriate screening recommendations and immunization status 1
• Multiple comorbidities: Organize problems by priority with clear assessment and plan for each 1
• Emergency department visits: Document clear disposition decisions (admission, discharge, transfer, observation) with clinical rationale 2

Template Maintenance

Regularly update templates based on changing guidelines and evidence to ensure patients receive the most effective care 2. Design templates to minimize documentation burden while capturing essential information, and ensure the format allows for efficient documentation of medical necessity 2.