How do I write a SOAP note?

How to Write a SOAP Note

A SOAP note is a structured medical documentation format consisting of four core sections: Subjective (patient's reported symptoms and history), Objective (measurable clinical findings), Assessment (clinical interpretation and diagnosis), and Plan (treatment and follow-up strategy). 1

Subjective Section

Document the patient's chief complaint in their own words, along with comprehensive background information:

• Record patient demographics and identification including name, address, telephone number, and additional contact information 2, 1
• Document age and weight as essential patient identifiers 2
• Obtain complete medication history including prescription medications, over-the-counter drugs, herbal supplements, and illicit substances, with specific dosage, time, route, and site of administration 2, 1
• Record all allergies and previous adverse drug reactions to prevent medication errors 2, 1
• Document relevant medical history including diseases, physical abnormalities, neurological impairments, previous hospitalizations, and family history particularly related to anesthesia 2
• Include pregnancy status for females of childbearing age 2
• Perform focused review of systems with special attention to cardiac, pulmonary, renal, or hepatic abnormalities that could alter treatment responses 2
• Query specifically about sleep-disordered breathing or obstructive sleep apnea as these increase airway risk 2

Objective Section

Record all measurable and observable clinical data:

• Document vital signs including heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 2, 1
• Note if vital signs cannot be obtained due to patient non-cooperation rather than omitting this information 2
• Include physical examination findings with focused evaluation of body systems relevant to the patient's condition 2, 1
• Perform airway assessment documenting tonsillar hypertrophy, abnormal anatomy (such as mandibular hypoplasia), or other factors increasing airway obstruction risk 2
• Record laboratory values, diagnostic test results, and other measurable data relevant to the clinical presentation 1
• Document physical status evaluation including ASA classification for procedural cases 2

Assessment Section

Synthesize subjective and objective data into clinical interpretation:

• Document positive findings noted during evaluation 2
• Identify the primary problem and formulate differential diagnoses 3
• Include clinical goals for the patient's condition (82% of assessment tools evaluate this component) 3
• Provide rationale for your clinical interpretation (69% of assessment tools include this) 3

Plan Section

Create a specific, actionable treatment strategy:

• Formulate a management plan addressing identified problems 2
• Document drug therapy with specific medications, dosages, routes, and duration 3
• Include non-drug therapy when applicable (though only 33% of tools assess this, it remains clinically important) 3
• Specify patient education provided regarding their condition and treatment (59% of plans include this) 3
• Establish follow-up with clear timelines and monitoring parameters (90% of plans include this) 3
• Include a copy of prescriptions or notes describing medication content 2
• Document instructions given to the responsible person regarding medications 2

Best Practices for Quality Documentation

Use a systematic approach to ensure completeness and avoid overlooking critical elements: 1

• Keep documentation simple, straightforward, and comprehensible using appropriate font type and layout for legibility 1
• Verify all documented information is factual and objective before finalizing 1
• Review notes for errors prior to completion 1
• Document all illnesses and injuries consistently with state or local licensing requirements 1

Special Considerations for Procedural Documentation

When documenting procedures, expand the standard SOAP format:

• Create a time-based record including name, route, site, time, dosage, and patient effect of all administered drugs 2
• Document "time out" confirmation of patient name, procedure to be performed, and site of procedure 2
• Record monitoring data including level of consciousness, responsiveness, and vital signs throughout the procedure 2
• Document adverse events and their treatment 4

Common Pitfalls to Avoid

• Never omit documentation when vital signs cannot be obtained; instead note the reason (e.g., patient non-cooperation) 2
• Do not overlook medication interactions by failing to document complete medication history 2
• Avoid inadequate allergy documentation as this creates patient safety risks 2
• Always document baseline health status for comparison during treatment 2

Quality Improvement

Regularly review documentation practices to identify areas for improvement and participate in peer review to maintain quality standards 1