Characteristics of Effective SOAP Notes
The best SOAP notes are those that document the patient's story in their own words, include all measurable clinical findings, provide accurate assessments with prioritized differential diagnoses, and create specific treatment plans—all while maintaining concise, organized, and factual documentation that avoids excessive copy-forward practices. 1, 2
Core Documentation Structure
Subjective Component
- Document the chief complaint in the patient's own words, capturing their symptoms, concerns, and perspective in detail 1, 2
- Include patient demographics: name, address, telephone number, and additional contact information 2
- Record relevant medical history including allergies, previous adverse drug reactions, and current medication history 2
- Capture the patient's story comprehensively to support information reuse across the care team 1
Objective Component
- Document all vital signs: heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 2
- Include physical examination findings relevant to the patient's current condition 2
- Record laboratory values, diagnostic test results, and other measurable clinical data 2
- Ensure all documented information is factual and objective rather than subjective interpretations 2
Assessment Component
- Provide a prioritized differential diagnosis rather than a single diagnosis when appropriate 3
- Include prognosis when relevant, particularly for serious conditions or when discussing goals of care 1
- Document patient assessment information that reflects current status 1
Plan Component
- Create treatment plans that prioritize goals and outline specific intervention strategies for risk reduction 1
- Document follow-up plans when necessary 4
- Communicate treatment and follow-up plans interactively with patients and appropriate family members in collaboration with the primary healthcare provider 1
Critical Documentation Practices
Organization and Clarity
- Use a systematic approach with appropriate flow and chronology to avoid overlooking important elements 2, 3
- Keep documentation simple, straightforward, and comprehensible 2
- Use appropriate font type and layout to ensure legibility 2
- Avoid dense information through structured formats with prominent subheadings 5
- Present information concisely and in an organized manner 3
Accuracy and Completeness
- Verify that all documented information is factual and objective before finalizing 2
- Review notes for errors before finalizing 2
- Document all illnesses and injuries consistently with state or local licensing requirements 2
- Ensure completeness by including all relevant components without omissions 6
Common Pitfalls to Avoid
- Never excessively copy-forward prior notes without editing, as this propagates errors and reduces clinical utility 1
- Avoid documenting symptoms under the Objective component—these belong in the Subjective section 6
- Do not omit your signature on documentation 6
- Avoid vague or non-specific plans that lack actionable details 3
Electronic Health Record Considerations
- Leverage EHR capabilities to display historical information in rich context while supporting critical thinking during documentation 1
- Support "write once, reuse many times" functionality with embedded tags identifying the original source of information 1
- Use structured data capture only where useful for care delivery or essential for quality assessment 1
Special Circumstances
For do-not-attempt-resuscitation orders, progress notes must indicate:
- Prognosis 1
- Descriptions of discussions with family and medical team 1
- Documented expressed wishes of patient and family decision-makers 1
- Unresolved issues 1
- Recommendations from treating team and consultants 1