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

SOAP Note Format and Structure

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 to ensure comprehensive patient care documentation. 1, 2

Subjective Section

The Subjective section captures the patient's perspective and history:

• Patient demographics and identification: Document name, address, telephone number, and additional contact information 1, 2
• Chief complaint: Record in the patient's own words, capturing their primary concern 1, 2
• History of present illness (HPI): Include onset, duration, characteristics, aggravating/alleviating factors, and associated symptoms 1
• Past medical history: Document previous diagnoses, surgeries, hospitalizations, and chronic conditions 1
• Medication history: List current medications with dosages and adherence patterns, including allergies and previous adverse drug reactions 1, 2
• Social history: Record smoking status, alcohol use, substance use, occupation, and living situation 1
• Review of systems (ROS): Organize by body system to capture symptoms not covered in the HPI 1

Objective Section

The Objective section contains measurable and observable data:

• Vital signs: Document heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1, 2
• Physical examination findings: Include findings relevant to the patient's condition, organized by body system 1, 2
• Laboratory values: Record all relevant diagnostic test results and measurable data 1, 2
• Imaging study results: Include radiographic and other imaging findings when applicable 1
• Vaccination status: Document immunization history and current status 1

Common pitfall: Students frequently document patient symptoms under the Objective component when they belong in the Subjective section—only 27.4% of students in one study correctly separated these components 3

Assessment Section

The Assessment section synthesizes clinical findings into diagnostic impressions:

• Primary diagnosis or problem list: Include each identified problem with supporting evidence from the subjective and objective data 1
• Severity assessment: Document the current status and acuity of each identified problem 1
• Risk assessment: Evaluate for relevant complications or comorbidities 1
• Disease staging information: Include when applicable to the patient's condition 1

In one study, 94.7% of students provided a possible diagnosis, but only 62.1% documented it accurately, highlighting the need for precision in this section 3

Plan Section

The Plan section outlines the management strategy:

• Treatment plan: Specify medications with exact dosages, duration, and therapeutic goals 1
• Diagnostic tests ordered: Document with clear rationale for each test 1
• Referrals: Include specialist consultations when indicated 1
• Patient education: Record disease management and self-care instructions provided 1
• Follow-up instructions: Specify timing of next appointment and parameters for earlier return 1
• Preventive care recommendations: Document age-appropriate screening and health maintenance 1

Research shows that only 56.7% of students planned appropriate diagnostic workups and 52.6% documented treatment plans, with accurate plan documentation occurring in just 38.0% of notes 3

Documentation Best Practices

Use a systematic approach with clear formatting to ensure completeness and avoid overlooking critical elements:

• Structure and organization: Use clear headings for each SOAP component with bullet points to organize information 1, 2
• Clarity: Keep documentation simple, straightforward, and comprehensible; avoid field-specific jargon that may confuse other providers 1, 2
• Accuracy: Verify all documented information is factual and objective; review notes for errors before finalizing 1, 2
• Signature: Always sign your notes—36.8% of student notes in one study lacked signatures, rendering them incomplete 3
• Brevity: Use concise language while maintaining necessary detail; flag important information with bold or highlighting 1
• Legibility: Use appropriate font type and layout to ensure readability 2

Special Clinical Scenario Considerations

For chronic disease management: Include disease-specific metrics (e.g., HbA1c for diabetes) and treatment goals 1

For medication management: Document reasons for dose modifications or deviations from standard regimens 1

For patients with multiple comorbidities: Organize problems by priority with a clear assessment and plan for each condition 1

For preventive care visits: Document age-appropriate screening recommendations and immunization status 1

Quality Improvement

• Regular review: Participate in peer review of documentation to maintain quality standards 2
• Continuous improvement: Regularly review documentation practices to identify areas for enhancement 1, 2
• Psychosocial documentation: Include psychosocial concerns and support needs, as these impact patient outcomes 1