How to write a SOAP Note

Documenting the patient visit is an important part of the process.  There are many ways that healthcare professionals can document their sessions. One of the most widely used methods is called a SOAP Note. Learning how to write a SOAP note can be one of the most effective ways for clinicians to document, assess, diagnose, and track plans for patients. While SOAP Notes are a great way to document, there are many other documentation methods that could be used by a health professional.

What is a SOAP Note?

A SOAP note is a widely used method of documentation by healthcare professionals to communicate patient information in a structured format. SOAP notes play a vital role in patient care and clinical decision-making. They provide a comprehensive record of the patient's health status, facilitate continuity of care between healthcare professionals, and serve as a legal and ethical documentation of the care provided. SOAP Notes also guide healthcare workers in assessing, diagnosing, and treating patients. Because SOAP notes are employed by a broad range of medical fields, their format can differ based on the practice and nature of the visit (e.g. well visit, progress note, sick visit, new patient intake, etc). However, all SOAP Notes should include Subjective, Objective, Assessment, and Plan sections. 

Parts of a SOAP Note

A SOAP note is organized into four main components: Subjective, Objective, Assessment, and Plan. Each section of the SOAP note serves a specific purpose. Let’s review the proper structure and components of a SOAP note:

• Subjective (S): This section includes information about the patient's symptoms, feelings, and concerns as reported by the patient or their caregiver. It may also include information about the patient's medical history and relevant social or family history.some text
  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Current Medications
  • Past Medical History
  • Past Surgical History
  • Family and Social History
  • Reason for Referral
  • Review of Systems (ROS)
  • Medication allergies

Note: Any opinions or observations you include in this section are attributed to who said them (e.g. yourself, patient themselves, caregiver). 

• Objective (O): This section contains observable and measurable data obtained through clinical examinations, diagnostic tests, or the healthcare provider's observations gathered from the session. It provides objective information about the patient's physical condition.some text
  • Vitals
  • Laboratory Results
  • Physical Exam
  • Physical, interpersonal, and psychological observations (e.g. body posture, general appearance, affect and behavior, etc)

Note: This section should consist of factual information that you observe and not include opinions or anything the patient has told you.

• Assessment (A): In this section, the healthcare provider analyzes and interprets the subjective and objective data to formulate a diagnosis or assessment of the patient's condition. It involves the healthcare provider's professional judgment and decision-making.some text
  • List of possible diagnoses 
  • Health status and need for lifestyle change

Note: You can include your impressions and interpretations including drawing from any clinical knowledge or DSM criteria/therapeutic models. 

• Plan (P): The Plan section outlines the treatment plan and interventions recommended for the patient.some text
  • Treatment
  • Medications prescribed
  • Diagnostic tests ordered,
  • Therapeutic procedures
  • Follow-up appointments
  • Patient education or counseling provided

Note: It can also include short and long term goals for your patient, what you plan to work on in the next session, or expectations for the duration of treatment. 

Tips for completing SOAP Notes

Documentation is essential for healthcare professionals to clearly and effectively communicate a patient's health status, ensure continuity of care, and adherence to best practices. Remember to tailor SOAP notes to your specific healthcare setting and always prioritize patient confidentiality and privacy in your documentation.

• Avoid using tentative language such as “may” or “seems.”
• Avoid using absolutes such as “always” or “never.”
• Avoid using words that suggest moral judgment, such as “good” or “bad.”
• Write legibly.
• Use simple language “layman’s terms.”
• Use clear and concise language (avoid slang, abbreviations, etc.)
• Use language that is culturally sensitive.
• Use correct spelling/grammar.
• Proofread your notes.
• Write your note as if you may have to defend its contents.
• When quoting a patient or caregiver, be sure to place exact words in quotation marks.