What is a SOAP Note?
A SOAP note is a standardized method of clinical documentation used by healthcare providers to record patient encounters. The acronym stands for Subjective, Objective, Assessment, and Plan ā four distinct sections that organize clinical information in a logical, consistent format.
SOAP notes create a clear record of the patient's condition, your clinical findings, your professional judgment, and the care plan. They facilitate communication between providers, support continuity of care, and serve as legal documentation of the encounter.
S ā Subjective
The Subjective section captures information reported by the patient (or caregiver). This is their story in their words ā what they're experiencing, how they feel, and what brought them in.
**Key Components:**
ā¢ **Chief Complaint (CC)**: The main reason for the visit in the patient's own words
ā¢ **History of Present Illness (HPI)**: Detailed description using OLDCARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity)
ā¢ **Review of Systems (ROS)**: Relevant positive and negative symptoms
ā¢ **Past Medical History (PMH)**: Relevant conditions, surgeries, allergies
ā¢ **Medications**: Current medications and compliance
ā¢ **Social/Family History**: When relevant to the complaint
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Subjective Section Tips
Always document the chief complaint in the patient's own words using quotation marks. For example: CC: "My chest feels tight and I can't catch my breath." This preserves the patient's voice and provides context for your assessment.
O ā Objective
The Objective section contains measurable, observable data that you or other clinicians have gathered. This is factual information ā what you can see, hear, measure, and verify.
**Key Components:**
ā¢ **Vital Signs**: BP, HR, RR, Temp, SpO2, Pain scale
ā¢ **Physical Exam Findings**: Systematic examination results
ā¢ **Lab Results**: Relevant laboratory values
ā¢ **Diagnostic Results**: Imaging, ECG, other test results
ā¢ **Observations**: General appearance, behavior, affect
Objective Documentation Standards
Follow these standards for objective documentation:
- ā¢Document all vital signs with units and context (e.g., 'BP 142/88 sitting, left arm')
- ā¢Use specific, measurable terms (avoid vague words like 'normal' without context)
- ā¢Include pertinent negatives (e.g., 'no edema, no JVD')
- ā¢Document what you actually assessed, not assumptions
- ā¢Include time stamps for critical values or changes
A ā Assessment
The Assessment is your clinical judgment ā your professional interpretation of the subjective and objective data. This is where you synthesize information and identify the problem(s).
**Key Components:**
ā¢ **Primary Diagnosis**: Most likely diagnosis based on evidence
ā¢ **Differential Diagnoses**: Other conditions being considered
ā¢ **Clinical Reasoning**: Brief explanation of your thinking
ā¢ **Risk Stratification**: Severity, acuity, stability
ā¢ **Problem List**: For complex patients with multiple issues
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Assessment Best Practices
Never copy-paste assessments from previous notes without updating them. Each assessment should reflect the current encounter and your current clinical judgment. Outdated assessments can lead to missed diagnoses and patient harm.
P ā Plan
The Plan outlines the next steps ā what you're going to do about the assessment. This should be specific, actionable, and tied to each problem identified.
**Key Components:**
ā¢ **Diagnostic Plan**: Tests, labs, imaging ordered
ā¢ **Therapeutic Plan**: Medications, treatments, interventions
ā¢ **Patient Education**: Instructions, counseling provided
ā¢ **Disposition**: Discharge, admit, transfer, follow-up
ā¢ **Contingency Plans**: When to return, warning signs
š Plan Documentation Example
**Good Plan:** 1. CBC, CMP, UA ā results pending 2. Acetaminophen 650mg PO q6h PRN pain 3. IV NS 1L bolus for dehydration 4. Patient educated on signs of worsening infection 5. Follow-up in 48 hours or sooner if fever >101Ā°F **Poor Plan:** "Continue current management, follow up as needed." The good plan is specific, actionable, and includes contingencies. The poor plan is vague and doesn't guide care.
Common SOAP Note Mistakes
Avoid these common documentation errors:
- ā¢Mixing subjective and objective information
- ā¢Using vague terms like 'WNL' without specifying what was assessed
- ā¢Failing to document pertinent negatives
- ā¢Assessment that doesn't match the S and O data
- ā¢Plan that doesn't address all problems in the assessment
- ā¢Copy-pasting from previous notes without updating
- ā¢Missing time stamps on critical findings
- ā¢Incomplete medication reconciliation