SOAP Note Format for Patient Documentation
The SOAP note format is a widely adopted, problem-oriented documentation structure consisting of four sequential sections: Subjective (patient's narrative and symptoms), Objective (measurable findings and examination data), Assessment (clinical reasoning and diagnosis), and Plan (treatment and follow-up actions). 1
Core Structure
Subjective Section
- Document the patient's narrative in their own words, including chief complaint, history of present illness, and relevant symptoms 2
- Capture the patient's perspective and experience, maintaining their voice when describing symptoms and concerns 2
- Include pertinent positive and negative findings relevant to the patient's concerns and chronic conditions 2
Objective Section
- Record measurable clinical findings, including vital signs, physical examination results, and diagnostic test data 1
- Document only clinically relevant positive and negative findings rather than exhaustive normal findings 2
- Use standardized terminology for consistency while avoiding excessive documentation that obscures key findings 2
Assessment Section
- Synthesize information from Subjective and Objective sections to formulate clinical reasoning and differential diagnosis 3, 4
- For each identified problem, document current status, relevant findings, and clinical thought process including uncertainties 2
- Use a problem-oriented approach that clearly identifies each patient issue 2
Plan Section
- Document specific management actions for each problem, including tests, treatments, medications, and patient education provided 2
- Include follow-up arrangements and anticipated course with and without treatment 5
- Record shared decision-making discussions and actions taken (or deliberately not taken) 1
Documentation Best Practices
Efficiency and Clarity
- Prioritize brevity and thoughtfulness over verbatim transcription of clinical interactions 1, 2
- Avoid "note bloat" where key findings are obscured by superfluous negative findings and irrelevant documentation 2
- Organize notes to facilitate quick retrieval of relevant information by future providers 2
Technology Considerations
- Use templates and macros judiciously to improve efficiency for standardized findings (normal physical exam, review of systems) 1
- Verify and update any copy-forward information to ensure accuracy and avoid propagating outdated data 2, 6
- Ensure final signed documentation accurately reflects what occurred during the patient-physician encounter 1
Common Pitfalls to Avoid
- Do not clone documentation where entries are worded exactly like previous entries, as this misrepresents medical necessity 1
- Avoid excessive use of drop-down lists and checkboxes that standardize away the heterogeneity making each encounter unique 1
- Do not allow EHR structure to drive the clinical interview at the expense of context and clinical detail 1
Legal and Quality Considerations
- SOAP notes serve as legal documents that must be accurate, unaltered, and establish accountability for documented information 2, 6
- Documentation should demonstrate clinical reasoning and support appropriate billing levels, but prioritize clinical communication over coding requirements 2
- Include sufficient detail to effectively communicate the clinical situation while maintaining conciseness 6