How do I write a SOAP note?

How to Write a SOAP Note

A SOAP note should systematically document four components: Subjective (patient's chief complaint and history), Objective (vital signs and physical examination findings), Assessment (clinical impression), and Plan (treatment and follow-up), with all information recorded factually and placed in the patient's medical record. 1

Subjective Component

Document the patient's chief complaint in their own words, along with comprehensive identifying information and relevant medical history 1:

• Patient demographics: Include name, address, telephone number, and additional contact information such as the patient's personal care provider or medical home 2, 1
• Chief complaint: Record exactly what the patient states as their reason for seeking care 1
• Medical history: Document allergies, previous adverse drug reactions, current medications, history of sedation or anesthesia complications, relevant hospitalizations, and family history 2, 1
• Review of systems: Focus on abnormalities that might affect the patient's condition, including cardiac, pulmonary, renal, or hepatic function 2

Objective Component

Record all measurable data and physical examination findings 1:

• Vital signs: Document heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 2, 1
• Physical examination: Include focused findings relevant to the patient's condition, such as airway evaluation (tonsillar hypertrophy, abnormal anatomy, Mallampati score) when appropriate 2, 1
• Laboratory and diagnostic data: Record all test results, imaging findings, and other measurable clinical data 1

Common pitfall: For uncooperative patients where vital signs cannot be obtained, document this circumstance explicitly rather than leaving the section blank 2

Assessment Component

Formulate your clinical impression based on the subjective and objective data:

• Synthesize the information to arrive at a diagnosis or differential diagnosis
• Document your clinical reasoning process
• Include physical status evaluation (such as ASA classification when relevant) 2

Plan Component

Document all interventions, prescriptions, and follow-up arrangements:

• Prescriptions: Include a copy of the prescription or detailed description of its content, along with instructions given to the responsible person 2
• Time-based documentation: For procedures or treatments, record the name, route, site, time, dosage/kilogram, and patient effect of administered drugs 2
• Follow-up: Specify return visit timing, monitoring parameters, and when to seek urgent care

Documentation Best Practices

Maintain accuracy, clarity, and completeness in all SOAP notes 1:

• Use systematic approach: Follow the SOAP format consistently to avoid overlooking important elements 1
• Ensure legibility: Keep documentation simple, straightforward, and comprehensible using appropriate font type and layout 1
• Verify accuracy: Confirm all documented information is factual and objective; review notes for errors before finalizing 1
• Archive properly: All documentation must be placed in the patient's medical record, whether paper or electronic 2

Critical consideration: When using electronic communication or telephone encounters, document date and time of contact, patient identification, reason for communication, relevant history and evaluation, assessment, plan, and disposition 3

Quality Improvement

Regularly review your documentation practices to maintain high standards 1:

• Identify areas for improvement through self-review 1
• Participate in peer review of documentation to maintain quality standards 1
• Ensure compliance with state or local licensing requirements for documenting all illnesses and injuries 1

Important caveat: For hospitalized patients, the current hospital record may suffice for documentation, but you must write a note confirming chart review, noting positive findings, and formulating a management plan 2