SOAP Note Format and Documentation Standards
The proper SOAP note format consists of four distinct sections—Subjective, Objective, Assessment, and Plan—each with specific required components that should be documented systematically using clear headings, bullet points, and factual language to ensure comprehensive patient care documentation. 1, 2
Subjective Section: Patient-Reported Information
Document the following patient-provided information:
- Chief complaint in the patient's own words, capturing exactly what the patient states as their primary concern 1
- History of present illness (HPI) including onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 1
- Past medical history with previous diagnoses, surgeries, and hospitalizations 1
- Medication history documenting current medications, dosages, and adherence patterns 1
- Social history including smoking status, alcohol use, substance use, occupation, and living situation 1
- Allergies and previous adverse drug reactions 2
- Review of systems (ROS) organized by body system 1
- Patient demographics including name, address, telephone number, and contact information 1, 2
Objective Section: Measurable Clinical Data
Record all observable and measurable findings:
- Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1, 2
- Physical examination findings relevant to the patient's condition, organized by body system 1, 2
- Laboratory values and diagnostic test results with all measurable data 1, 2
- Imaging study results when applicable 1
- Vaccination status and immunization history 1
Assessment Section: Clinical Interpretation
Synthesize the subjective and objective data into clinical reasoning:
- Primary diagnosis or problem list with supporting evidence from the S and O sections 1
- Severity assessment and current status of each identified problem 1
- Risk assessment for relevant complications or comorbidities 1
- Disease staging information when applicable 1
- Differential diagnoses considered and rationale for primary diagnosis 3
Plan Section: Management Strategy
Detail the specific interventions and follow-up:
- Medications with specific dosages, duration, and goals of therapy 1
- Diagnostic tests ordered with clear rationale for each 1
- Referrals to specialists when indicated 1
- Patient education provided regarding disease management and self-care 1
- Follow-up instructions including specific timing of next appointment 1
- Preventive care recommendations 1
Documentation Best Practices
Use a systematic approach with clear formatting to ensure completeness and avoid errors:
- Structure: Use clear headings for each SOAP component with bullet points to organize information 1, 2
- Language: Keep documentation simple, straightforward, and comprehensible; avoid field-specific jargon that may confuse other providers 1
- Objectivity: Ensure all documented information is factual and objective, not interpretive or subjective in the O, A, and P sections 1, 2
- Accuracy: Review notes for errors before finalizing 1, 2
- Clarity: Use appropriate font type and layout; bold or highlight important information 1
- Abbreviations: Avoid abbreviations that may be misinterpreted 1
- Patient comprehension: Document specific details about the patient's understanding of treatment plans 1
Special Clinical Scenario Considerations
Tailor documentation to specific contexts:
- Chronic disease management: Include disease-specific metrics and goals (e.g., HbA1c targets for diabetes) 1
- Medication adjustments: 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
- Psychosocial concerns: Document need for support services 1