What should be included in a general SOAP note template for clinical use?

SOAP Note Template for Clinical Use

A comprehensive SOAP note should include four core sections—Subjective, Objective, Assessment, and Plan—with specific standardized elements in each section to ensure complete documentation and support clinical decision-making. 1, 2

Template Structure

SUBJECTIVE Section

Patient Demographics and Identification:

• Full name, date of birth, address, telephone number, and additional contact information 1, 2
• Medical record number and date of encounter 1

Chief Complaint:

• Document in the patient's own words 1, 2
• Include specific quotes when possible 1

History of Present Illness (HPI):

• Onset: When symptoms began (exact date/time) 1
• Duration: How long symptoms have persisted 1
• Characteristics: Quality and nature of symptoms 1
• Aggravating factors: What makes symptoms worse 1
• Alleviating factors: What provides relief 1
• Associated symptoms: Related complaints 1

Past Medical History:

• Previous diagnoses with dates 1
• Prior surgeries and hospitalizations 1
• Chronic conditions and their management status 1

Medication History:

• Current medications with specific dosages 1
• Frequency and route of administration 1
• Adherence patterns and barriers 1
• Previous adverse drug reactions 2
• Known drug allergies 2

Social History:

• Smoking status (pack-years if applicable) 1
• Alcohol use (quantity and frequency) 1
• Substance use 1
• Occupation and occupational exposures 1
• Living situation and support systems 1

Review of Systems (ROS):

• Organized by body system (constitutional, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic, skin) 1
• Document pertinent positives and negatives 1

OBJECTIVE Section

Vital Signs:

• Heart rate (beats per minute) 1, 2
• Blood pressure (systolic/diastolic in mmHg) 1, 2
• Respiratory rate (breaths per minute) 1, 2
• Oxygen saturation (percentage on room air or supplemental oxygen) 1, 2
• Temperature (degrees Fahrenheit or Celsius) 1, 2
• Weight and height (for BMI calculation when relevant) 1

Physical Examination Findings:

• Organized by body system 1, 2
• General appearance and level of distress 1
• System-specific findings relevant to chief complaint 1, 2
• Document normal findings for examined systems 1

Laboratory Values:

• Recent lab results with reference ranges 1, 2
• Date of collection 1
• Trending data when applicable 1

Diagnostic Test Results:

• Imaging study results with dates 1, 2
• Electrocardiogram findings 1
• Other diagnostic procedures 1

Immunization Status:

• Current vaccination record 1
• Due or overdue immunizations 1

ASSESSMENT Section

Primary Diagnosis/Problem List:

• List problems in order of priority 1, 2
• Include ICD-10 codes when applicable 1
• Supporting evidence from subjective and objective data 1

Severity Assessment:

• Current status of each identified problem (stable, improving, worsening, new) 1
• Disease staging information when applicable 1

Risk Assessment:

• Complications or comorbidities 1
• Prognostic information for serious conditions 3

Differential Diagnosis:

• Alternative diagnoses considered 1
• Rationale for ruling out alternatives 1

PLAN Section

Pharmacological Management:

• Medications prescribed with specific drug names 1, 3
• Exact dosages and frequency 1, 3
• Route of administration 1
• Duration of therapy 1
• Goals of therapy for each medication 1
• Rationale for dose modifications 1

Diagnostic Testing:

• Tests ordered with specific rationale 1, 3
• Urgency level (stat, routine, scheduled) 1
• Expected timeframe for results 1

Referrals:

• Specialist consultations with indication 1, 3
• Urgency of referral 1

Patient Education:

• Disease management instructions provided 1, 3
• Self-care recommendations 1
• Warning signs requiring immediate attention 1
• Documentation of patient comprehension 1

Follow-up Instructions:

• Timing of next appointment (specific date or timeframe) 1, 3
• Parameters for earlier follow-up 1
• Contact instructions for questions or concerns 1

Preventive Care:

• Age-appropriate screening recommendations 1
• Lifestyle modifications discussed 1
• Immunizations administered or scheduled 1

Documentation Best Practices

Systematic Approach:

• Use consistent formatting with clear headings for each section 1, 2
• Follow the same organizational structure for every note 1, 2

Clarity and Conciseness:

• Keep documentation simple, straightforward, and comprehensible 1, 2, 3
• Use bullet points to organize information 1
• Avoid field-specific jargon that may confuse other providers 1

Accuracy and Objectivity:

• Document only factual and objective information 1, 2
• Avoid subjective interpretations without supporting data 1, 2
• Review notes for errors before finalizing 1, 2

Completeness:

• Document all relevant clinical information without excessive copying from prior notes 3
• Include psychosocial concerns and support needs 1
• Flag important information by bolding or highlighting 1

Quality Improvement:

• Regularly review documentation practices to identify improvement areas 1, 2
• Participate in peer review of documentation 2
• Ensure compliance with state and local licensing requirements 2

Special Clinical Scenarios

Chronic Disease Management:

• Include disease-specific metrics (e.g., HbA1c for diabetes, blood pressure goals for hypertension) 1
• Document progress toward treatment goals 1

Multiple Comorbidities:

• Organize problems by priority 1
• Provide clear assessment and plan for each condition 1

Cancer Care:

• Include staging information 1
• Document treatment regimen details and goals of therapy 1

Do-Not-Attempt-Resuscitation Orders:

• Indicate prognosis 3
• Describe discussions with family and medical team 3
• Document expressed wishes of patient and family decision-makers 3
• Note unresolved issues 3
• Include recommendations from treating team and consultants 3