What is the SOAP (Subjective, Objective, Assessment, and Plan) framework for approaching a patient?

SOAP Framework for Patient Encounters

The SOAP (Subjective, Objective, Assessment, and Plan) framework is a structured clinical documentation method that organizes patient information into four sequential sections to guide clinical reasoning and ensure comprehensive care delivery. 1

Framework Components

Subjective Section

Document the patient's narrative and chief complaint in their own words, capturing their perspective on symptoms, concerns, and functional limitations. 1

• Record patient demographics including name, address, telephone number, and emergency contact information 1
• Document the chief complaint exactly as stated by the patient 1
• Include relevant medical history: allergies, previous adverse drug reactions, current medications (prescription, over-the-counter, and supplements), and past medical conditions 1
• Capture the patient's description of symptom evolution, including onset, duration, severity, and aggravating/relieving factors 2
• Document patient-reported functional impacts on daily activities, work capacity, and social functioning 3
• Record patient goals, values, and preferences regarding treatment decisions 3

Objective Section

Record all measurable clinical findings, vital signs, physical examination results, and diagnostic test data. 1

• Document vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1
• Record focused physical examination findings relevant to the presenting complaint 1
• Include laboratory values, imaging results, and other diagnostic test data 1
• Document medication reconciliation findings when bottles are brought to the visit 4
• Record objective functional assessments using standardized tools (e.g., activities of daily living scales, mobility assessments) 4

Assessment Section

Synthesize subjective and objective data to formulate diagnostic reasoning, differential diagnoses, and clinical impressions. 5

• Integrate information from both Subjective and Objective sections to create a coherent clinical picture 5
• Document primary and secondary problems/diagnoses with supporting evidence 5
• Include differential diagnoses with reasoning for inclusion or exclusion 1
• Note disease severity, stability, or progression compared to previous visits 4
• Document prognosis when relevant, particularly for serious conditions or when discussing goals of care 2

Plan Section

Create an actionable treatment strategy that addresses each identified problem with specific interventions, follow-up, and patient education. 2

• Develop problem-specific plans for diagnostic testing, therapeutic interventions, and symptom management 5
• Document medication changes including additions, discontinuations, and dose adjustments 3
• Include referrals to specialists or other healthcare team members 3
• Specify follow-up timing and parameters for reassessment 4
• Document patient education provided and shared decision-making discussions 3
• Record preventive care recommendations (vaccinations, screening tests) 3
• Note any advance care planning discussions or directives 3

Implementation Best Practices

Documentation Quality

Write notes that are complete, concise, accurate, and immediately useful to the entire care team. 2

• Avoid excessive copy-forward from previous notes without editing, as this propagates errors 2
• Use clear, straightforward language with appropriate medical terminology 1
• Ensure all documented information is factual and objective 1
• Review notes for errors before finalizing 1

Multi-Domain Assessment Integration

Expand beyond traditional medical assessment to include physical functioning, mental/emotional health, and social/environmental factors. 3

The American College of Cardiology recommends incorporating a four-domain framework into SOAP documentation: 3

• Medical domain: Lifestyle factors, comorbidities, medication adherence, polypharmacy review 3
• Physical functioning domain: Daily activity levels, nutritional status, mobility, fall risk, frailty 3
• Mind and emotion domain: Patient priorities, cognitive function, mood, anxiety, depression 3
• Social and environmental domain: Health literacy, family support, socioeconomic factors, physical environment 3

Electronic Health Record Optimization

Leverage EHR capabilities to enhance documentation efficiency while maintaining clinical utility. 2

• Use pre-visit questionnaires to capture patient-reported information before the encounter 4
• Implement structured data capture only where it improves care delivery or quality assessment 2
• Create smart phrases or templates for commonly used assessment tools 3
• Display historical information in context while supporting critical thinking 2

Common Pitfalls to Avoid

• Incomplete subjective documentation: Failing to capture the patient's perspective in their own words reduces the narrative's clinical value 2
• Unfocused objective findings: Recording irrelevant physical examination findings instead of problem-focused assessments wastes documentation time 6
• Weak assessment synthesis: Simply listing problems without integrating subjective and objective data fails to demonstrate clinical reasoning 5
• Vague plans: Using nonspecific language like "follow up as needed" instead of concrete timelines and parameters 4
• Neglecting patient goals: Omitting documentation of shared decision-making and patient preferences undermines patient-centered care 3