What is the proper way to document progress notes in a patient's medical record using the SOAP (Subjective, Objective, Assessment, and Plan) format?

Proper Documentation of Progress Notes Using SOAP Format

Progress notes should be documented using the SOAP (Subjective, Objective, Assessment, and Plan) format, which is a widely adopted interdisciplinary documentation standard that captures initial visits and monitors follow-up care effectively. 1

Core SOAP Components

Subjective Section

• Document the patient's story in as much detail as required to accurately retell it, capturing symptoms, concerns, and the patient's perspective 1
• Include relevant history that the patient reports, their current complaints, and any changes since the last visit 1
• Record patient-generated data while maintaining clear identification of the source 1

Objective Section

• Document measurable clinical findings including vital signs (pulse rate and regularity, blood pressure), physical examination findings (auscultation of heart and lungs, inspection of extremities), and relevant test results 1
• Include results from diagnostic testing such as 12-lead ECG, laboratory values, and imaging studies as applicable 1
• Record observations about the patient's physical functioning, cognitive status, and any post-procedure wound assessments 1

Assessment Section

• Synthesize information from the Subjective and Objective sections to formulate clinical reasoning about the patient's condition 2
• Document your clinical interpretation, differential diagnoses, and analysis of the patient's problems 3, 4
• Include prognosis when relevant, particularly for serious conditions or when discussing goals of care 1

Plan Section

• Document specific interventions, tests, treatments, and management strategies that address the problems identified in the Assessment 2, 4
• Create a treatment plan that prioritizes goals and outlines intervention strategies for risk reduction 1, 5
• Include medication management details with specific doses, frequencies, and any adjustments made 1
• Document patient education provided and follow-up arrangements 1

Critical Documentation Principles

Accuracy and Completeness

• Document observations completely, concisely, and accurately to support information reuse across the care team 1
• Never replace original documentation when making corrections; amendments should be added as supplementary information with clear metadata including timestamps and author identification 6
• Avoid excessive copy-forward of prior notes without editing, as this propagates errors and reduces clinical utility 1

Special Circumstances Documentation

For DNAR Orders and End-of-Life Care:

• Progress notes accompanying do-not-attempt-resuscitation orders must indicate prognosis, describe discussions with family and medical team, document expressed wishes of patient and family decision-makers, note unresolved issues, and include recommendations from treating team and consultants 1

For Treatment Planning:

• Document patient assessment information that reflects current status and guides development of prioritized goals with intervention strategies 1, 5
• Communicate treatment and follow-up plans interactively with patients and appropriate family members in collaboration with the primary healthcare provider 1

Common Pitfalls to Avoid

• Do not use templates or macros without thoughtful review and editing, as they can compromise accuracy when misused 1
• Avoid documentation that merely checks boxes without substantive clinical narrative 1
• Do not copy entire prior notes forward without verifying accuracy and relevance to the current encounter 1
• Ensure that when reviewing prior information, you actively edit and attest to its current accuracy rather than blindly incorporating it 1

Electronic Health Record Considerations

• EHR systems should support "write once, reuse many times" with embedded tags identifying the original source of information 1
• Leverage EHR capabilities to display historical information in rich context while supporting critical thinking during documentation 1
• Use structured data capture only where useful for care delivery or essential for quality assessment 1
• Maintain the patient narrative as the primary focus while incorporating structured elements appropriately 1