What should be included in a SOAP note?

SOAP Note Components and Documentation Standards

Essential Structure

A SOAP note must include four core sections: Subjective (patient-reported information), Objective (measurable clinical data), Assessment (clinical interpretation), and Plan (management strategy), with specific required elements in each section to ensure comprehensive documentation. 1, 2

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Subjective Section

The subjective component captures the patient's perspective and relevant background:

• Patient demographics and identification: Document name, address, telephone number, and emergency contact information 3, 1, 2
• Chief complaint: Record in the patient's own words 1
• History of present illness: Include duration, progression, and character of symptoms 2
• Medication history: Document all prescription medications, over-the-counter drugs, herbal supplements, and illicit substances 3, 2
• Allergy history: Record all allergies and previous adverse drug reactions with specific details 3, 1, 2
• Relevant medical history: Include pertinent diseases, physical abnormalities, previous hospitalizations, and seizure disorders 2
• Pregnancy status: Document for all females of childbearing age 2
• Review of systems: Focus on cardiac, pulmonary, renal, and hepatic function abnormalities 2

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Objective Section

The objective component includes all measurable and observable data:

• Vital signs: Heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 3, 1, 2
  • If vital signs cannot be obtained due to patient non-cooperation, document this circumstance explicitly 3, 2
• Physical examination findings: Include focused evaluation of body systems relevant to the patient's condition 1, 2
• Airway assessment (when relevant): Document tonsillar hypertrophy, abnormal anatomy (mandibular hypoplasia), or high Mallampati score 3
• Laboratory values and diagnostic test results: Record all measurable data relevant to the clinical presentation 1
• Physical status evaluation: Include ASA classification for procedural cases 3, 2

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Assessment Section

The assessment synthesizes clinical findings into diagnostic impressions:

• Problem identification: List all active problems identified from subjective and objective data 2
• Clinical interpretation: Document positive findings noted during evaluation 2
• Differential diagnosis considerations: When applicable, note alternative diagnoses being considered 4

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Plan Section

The plan outlines the management strategy:

• Therapeutic interventions: Document both drug and non-drug therapies 2
• Diagnostic testing: Include rationale for ordered tests 3
• Patient education and counseling: Record instructions provided 4
• Follow-up arrangements: Specify timing and method (telephone or face-to-face) 3
• Medication prescriptions: Include copy of prescription or detailed description with instructions given to the patient 3, 2
• Monitoring parameters: Define what will be tracked and when 3

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Documentation Best Practices

Accuracy and Completeness

• Use systematic approach: Follow a consistent format to avoid omitting important elements 1
• Verify factual accuracy: Ensure all documented information is objective and factual 1
• Review before finalizing: Check for errors prior to completing the note 1
• Document chart review: For hospitalized patients, note that the chart was reviewed, positive findings were identified, and a management plan was formulated 3, 2

Clarity and Organization

• Keep documentation simple and straightforward: Use non-technical language when appropriate and ensure comprehensibility 3, 1
• Use appropriate formatting: Select font type and layout that ensure legibility 1
• Time-based recording: For procedures, document name, route, site, time, dosage/kilogram, and patient effect of all administered drugs 3, 2

Quality Improvement

• Regular practice review: Identify areas for improvement in documentation habits 1
• Participate in peer review: Maintain quality standards through collaborative evaluation 1

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Critical Pitfalls to Avoid

• Never omit vital signs documentation: If unobtainable, explicitly state the reason (e.g., patient non-cooperation) 3, 2
• Never overlook medication interactions: Complete medication history is essential to prevent adverse events 2
• Never skip allergy documentation: Inadequate recording of allergies and previous adverse reactions creates serious safety risks 2
• Never prescribe sedating medications for home administration: Prescription medications for procedural sedation must only be given under direct supervision by trained personnel, as deaths have occurred from home administration 3
• Never fail to document baseline status: This is essential for comparison during treatment and follow-up 2
• Never use actual body weight for obese patients: Most drug doses should be adjusted to ideal body weight rather than actual weight 3

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Special Considerations for Telemedicine

When conducting televisits, additional documentation is required:

• Document consent: Include disclaimer such as "teleconsultation is provided with the consent of the patient" 3
• Note platform used: Specify whether video visit, telephone call, or other method was employed 3
• Record limitations: Document any aspects of physical examination that could not be performed remotely 3
• Secure communication: Ensure all data management complies with privacy regulations (e.g., GDPR in European Union) 3