What is the purpose and recommended use of a SOAP (Subjective, Objective, Assessment, Plan) note in patient care?

SOAP Note Purpose and Recommended Use

The primary purpose of SOAP (Subjective, Objective, Assessment, Plan) notes is to support patient care and improve clinical outcomes through enhanced communication, serving as a systematic documentation framework that captures the patient's story, clinical findings, clinical reasoning, and treatment planning. 1, 2

Core Purpose and Function

SOAP notes function as the foundational structure for documenting patient encounters and monitoring care progression, organizing clinical information into four distinct sections that facilitate clinical reasoning and care continuity. 2, 3 The American Academy of Pediatrics specifically recommends the SOAP format for capturing both initial visits and monitoring follow-up care effectively. 3

The framework serves multiple critical functions:

• Documents the patient's narrative in their own words, including chief complaints, symptoms, concerns, and the patient's perspective in the Subjective section. 1, 2, 3
• Records measurable clinical data including vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, temperature), physical examination findings, laboratory values, and diagnostic test results in the Objective section. 2, 4
• Synthesizes clinical reasoning by analyzing the relationship between subjective complaints and objective findings to formulate diagnoses or problem lists in the Assessment section. 5
• Establishes actionable treatment strategies with prioritized goals and intervention plans in the Plan section. 3, 4

Essential Documentation Components

Subjective Section Requirements

Document patient demographics, identification information, chief complaint in the patient's own words, and comprehensive medical history. 2 This must include:

• Allergies and previous adverse drug reactions 2, 4
• Complete medication history (prescription, over-the-counter, herbal supplements, illicit drugs) 2, 4
• Relevant diseases, physical abnormalities, and previous hospitalizations 4
• Pregnancy status for females of childbearing age 4

Objective Section Requirements

Record all measurable clinical findings systematically. 2, 4 Critical elements include:

• Complete vital signs with documentation if unobtainable due to patient non-cooperation 2, 4
• Focused physical examination findings relevant to the presenting condition 2, 4
• Laboratory values and diagnostic test results 2
• Airway assessment including tonsillar hypertrophy or anatomical abnormalities 4

Assessment Section Requirements

Synthesize information from Subjective and Objective sections to formulate clinical impressions. 3, 5 The assessment should:

• Document positive findings noted during evaluation 4
• Include prognosis when relevant, particularly for serious conditions 3
• Reflect current patient status to guide goal development 3

Plan Section Requirements

Create treatment plans that prioritize goals and outline specific intervention strategies. 3, 4 The plan must:

• Document prescribed medications with dosage, route, and instructions 4
• Include follow-up plans and monitoring strategies 6
• Communicate interactively with patients and family members 3

Best Practices for Implementation

Use a systematic approach to ensure completeness while maintaining clarity and conciseness. 2 The American Academy of Pediatrics emphasizes:

• Keep documentation simple, straightforward, and comprehensible with appropriate formatting for legibility 2
• Verify all information is factual and objective before finalizing notes 2
• Review notes for errors prior to completion 2

Critical Documentation Principles

The clinical record should include the patient's story in as much detail as required to retell the story. 1 This principle from the American College of Physicians emphasizes that documentation must capture sufficient narrative detail to support care continuity across providers and settings.

Avoid excessive copy-forward of prior notes without editing, as this propagates errors and reduces clinical utility. 1, 3 When previously documented information remains accurate and adds value, use a "review/edit/attest and copy/forward" approach rather than blind copying. 1

Document observations completely, concisely, and accurately to support information reuse across the care team. 3 Electronic health record systems should support "write once, reuse many times" with embedded tags identifying original information sources. 3

Common Pitfalls to Avoid

Do not fail to document when vital signs cannot be obtained due to patient non-cooperation—this absence of data is itself clinically relevant information. 4

Never omit medication history that could interact with planned treatments, as this creates significant patient safety risks. 4

Avoid inadequate documentation of allergies and previous adverse reactions, which represents a critical safety documentation failure. 4

Do not neglect baseline health status documentation, as this prevents meaningful comparison during treatment monitoring. 4

Quality Improvement Considerations

Regularly review documentation practices to identify improvement areas and participate in peer review to maintain quality standards. 2 This ongoing quality assessment ensures SOAP notes continue to serve their primary purpose of supporting patient care and clinical outcomes.

For special circumstances such as do-not-attempt-resuscitation orders, progress notes must indicate prognosis, describe discussions with family and medical team, document expressed wishes, note unresolved issues, and include recommendations from treating team and consultants. 3