Mastering the SOAP Note: A Guide for Medical Students and Healthcare Professionals

SOAP notes are a fundamental tool for healthcare professionals. Whether you're a medical student just starting your clinical rotations, a seasoned therapist, or any other healthcare provider, mastering the art of writing effective SOAP notes is crucial for delivering high-quality patient care and ensuring clear communication within the healthcare team. This article provides a comprehensive guide to SOAP notes, offering examples, best practices, and insights to help you create concise, accurate, and informative documentation.

What is a SOAP Note?

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. SOAP notes represent a structured approach to documenting patient encounters and clinical findings. They are a systematic way to capture specific information about a client and certain aspects of the session. This format allows healthcare professionals to record and communicate essential details about a patient's condition, treatment, and progress in a clear and organized manner.

The SOAP note was developed by Dr. Lawrence Weed in the 1960s at the University of Vermont as part of the Problem-Oriented Medical Record (POMR). While the POMR wasn't widely adopted, the SOAP format gained popularity across various disciplines.

The Four Components of a SOAP Note

Let's break down each component of the SOAP note in detail:

S: Subjective

The Subjective section captures the patient's perspective and experience. It includes information that the patient reports, such as their symptoms, concerns, and the reason for their visit. This section is about the patient’s narrative. It includes a statement about relevant client behavior or status.

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Key elements of the Subjective section:

• Chief Complaint (CC): The main reason the patient is seeking medical attention. This is reported by the patient and can be a symptom, condition, previous diagnosis, or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper. Examples include chest pain, decreased appetite, shortness of breath.
• History of Present Illness (HPI): A detailed account of the patient's chief complaint, including its onset, location, duration, character, alleviating and aggravating factors, and any associated symptoms. The HPI begins with a simple one-line opening statement including the patient's age, sex, and reason for the visit. Example: 47-year-old female presenting with abdominal pain.
  • An acronym often used to organize the HPI is termed “OLDCARTS”:
    • Onset: When did the CC begin?
    • Location: Where is the CC located?
    • Duration: How long has the CC been going on for?
    • Characterization: How does the patient describe the CC?
    • Alleviating and Aggravating factors: What makes the CC better or worse?
    • Radiation: Does the pain radiate anywhere?
    • Timing: Is the pain constant or intermittent?
    • Severity: How severe is the pain on a scale of 1 to 10?
• Past Medical History (PMI): Relevant past medical conditions, surgeries, allergies, and medications. Medical history includes pertinent current or past medical conditions. Surgical history: Try to include the year of the surgery and surgeon if possible. Family history: Include pertinent family history. Current medications and allergies may be listed under the Subjective or Objective sections.
• Relevant Personal and Social History: Information about the patient's lifestyle, occupation, social support, and other factors that may impact their health.
• Direct Quotes: Use quotation marks to document the patient's exact words when they are particularly relevant or insightful.

Examples of content to include:

• "Jon states, “I didn’t sleep well last night and I’ve felt irritable all day.” We discussed his sleeping patterns and current stressors as possible reasons for his lack of sleep."
• "Jon reports bouts of depressive episodes and crying spells in the past week and says, “I just start crying out of nowhere. I don’t know where it’s coming from.” During last week’s session, I remember Jon mentioning the anniversary of his mother’s death; we talked about this being a possible trigger for his current emotional state."
• Client’s chief complaint, presenting problem, and any other relevant information, including direct quotes from the client
• Any relevant personal or medical issues that may impact or influence the client’s day-to-day routine
• A complete account of the client’s description of symptoms*Consider only information that you feel is relevant and statements from the client, loved ones, or teachers that can be attributed to the client’s mood, motivation, awareness, and willingness to participate.

Content to avoid:

• Statements without supporting facts. Statements such as “Client was willing to participate” is an opinion until you provide facts to support this observation.
• Statements without supporting facts
• Do not include statements without supporting facts. Statements such as “Client was willing to participate” is an opinion until you provide facts to support this observation.
• Tentative language such as “may” or “seems.”
• Absolutes such as “always” and “never.”

O: Objective

The Objective section contains factual and measurable data gathered during the patient's visit. This includes observable, quantifiable, and measurable data. It includes information that the healthcare provider observes or measures, such as vital signs, physical examination findings, and laboratory results. This part of the note includes factual documentation about the client including a client’s diagnosis, behavioral and/or physical symptoms, appearance, orientation, and mood/affect.

Key elements of the Objective section:

• Vital Signs: Document the patient's blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. The format to use is: BP: HR: RR: SaO2: _ T:
  • BP: Blood pressure
  • HR: Heart rate, between 60-100 is considered normal in adults
  • RR: Respiratory rate 18-20 is the average.
  • SaO2: Oxygen Saturation. In a normal healthy person, this is usually 98-100% on room air (sometimes abbreviated RA). If a patient is sicker, like in Chronic Obstructive Pulmonary Disease (COPD), this can be lower, usually 88-92%.
  • You should specify how the patient is breathing, usually in RA (room air), TM (tracheal mask), or Nasal Prongs (NP)
  • If the patient is receiving oxygen, note how many liters of oxygen they are receiving, OR how much inspired oxygen. In normal atmospheric air (e.g. room air), it is 20% inspired oxygen. Other times, if they are receiving exogenous oxygen, they may receive a higher content of oxygen (e.g. 32%).
  • T: Temperature. Greater than 38.5 degrees Celsius is considered “febrile”. Greater than 40.1 degrees Celsius starts causing protein denaturation and therefore possible neurological changes.*AVSS: usually is an abbreviation for “All vital signs stable”, but it is good practice to specify the vital signs in your note.
• Physical Exam Findings: Record relevant findings from your physical examination, including observations about the patient's appearance, posture, gait, and any specific abnormalities.CVS: Cardiovascular findingsResp: Respiratory FindingsAbdo: Abdominal ExamPVS: Peripheral Vascular ExamNeuro: Neurological exam. It is good to include whether the patient is alert and oriented
• Laboratory and Imaging Results: Include relevant results from blood tests, urine tests, X-rays, CT scans, and other diagnostic procedures.
• Mental Status: How the client presented themselves (affect, behavior, eye-contact, nervousness, talkativeness) based on your observations.
• Recognition and review of the documentation of other clinicians.

Examples:

• "Jon is alert. He is oriented to time and place and he’s actively participating during today’s session as indicated by positive responses and prompt replies."
• "Jon displays a mostly flat/blunted affect, hygiene is below baseline. He takes several seconds to respond to questions I ask him during the session."*Client’s strengths*Client’s mental status*Client’s ability to participate in the session*Client’s responses to the process*Written materials such as reports from other providers, psychological tests, or medical records (if applicable)

Content to avoid:

• General statements without supporting data
• Avoid assumptive statements pertaining to behavior
• Labels
• Personal judgments
• Value-laden language
• Opinionated statements (personal rather than professional opinions)
• Words/phrases that have negative connotations and/or are open to personal interpretations (ex: uncooperative, obnoxious, normal, drunk, spoiled)
• Example: “Jon arrived drunk and was acting rude and obnoxious during today’s session.”*Global summary of an intervention e.g.

A: Assessment

The Assessment section is where you analyze and interpret the subjective and objective information to form a clinical impression or diagnosis. Assimilate S. and O. section. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. You use your professionally acquired knowledge to interpret the information given by the client during the session and implement clinical knowledge and understanding (DSM/Therapeutic Model, identify themes or patterns).

Key elements of the Assessment section:

• Problem List: A prioritized list of the patient's identified problems or diagnoses, based on the subjective and objective data.
• Differential Diagnosis: A list of possible diagnoses, ranked from most to least likely, along with a brief discussion of the reasoning behind each possibility.
• Progress: Progress, regression, or plateau of client progress.*Update/include DSM criteria observations exhibited by the client.

Examples of content to include:

• Client appeared unusually disheveled, exhibited excessive anxiety and worry toward partner's threat of abandonment and denial of autonomy
• Client presented an abundance of guilt and shame due to infidelity from their partner; provider feels this may contribute to the immoderate emotional response and intemperate consumption of alcohol the client is currently experiencing
• Client appears to continue experiencing anxiety
• Client continues to experience family-related stressors
• Client exhibited signs of moderate depression
• Client anxiety has increased in severity and appears to meet the criteria for GAD*Adverse, as well as positive response, should be documented in re-assessment.*A prioritised problem list is generated with impairments linked to functional limitations.

Content to avoid:

• Repeating previous statements in the S and O sections.*The assessment is too vague e.g.

P: Plan

The Plan section outlines the course of action to address the patient's problems or diagnoses. This part outlines the next course of action as far as the treatment plan goes, given the preceding information gathered during your session. Detail the plans for the client.

Key elements of the Plan section:

• Further Testing: Specify any additional tests or consultations needed to confirm a diagnosis or rule out other possibilities. State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative.
• Treatment: Describe the specific treatments or interventions that will be implemented, including medications, therapies, and lifestyle modifications. Focus on things both parties have agreed to. Note nutritional, physical, and medical attributes that will contribute to the client’s therapeutic goals.Note any progression/regression client has made in treatment.Include implementation details. Ensure planning is aligned with assessment and direct.
• Referrals: Indicate any referrals to specialists or other healthcare providers. Specialist referral(s) or consults.
• Patient Education: Outline the information and instructions provided to the patient regarding their condition, treatment, and self-care.
• Follow-up: Specify the timing and nature of follow-up appointments or monitoring.*The therapist should report on what the patient's home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

Examples of content to include:

• “Client will consult with a licensed nutritionist, in order to create a healthy diet and lifestyle plan.”
• “Client will begin yoga classes at the local gym.”
• “Client is committed to attending group therapy sessions for eating disorders.”*Focus on your next steps for the upcoming session. Stay aligned with your overall treatment plan without reinstating it in full in this section.*Introduce designated assessments to assess the client's focus and uncontrollability.*Focus on client's reported symptoms or issues in daily functioning (frequency, duration, intensity, and type), if applicable.*Continue to build trust and confidence with the client to allow space for exploration of previous events similar to current stressors, and explore those conclusions.

Content to avoid:

• Restating overall treatment plan (as opposed to goals for the next session)
• Unrealistic, immeasurable goals to be accomplished before the client’s next session*Vague description of the plan e.g.

SOAP Note Examples

Here are a couple of examples of SOAP notes in different clinical settings:

Example 1: Primary Care Visit

S: The patient reports not feeling well today, "I'm very tired".O: Auscultation findings: scattered rhonchi all lung fields.A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been compliant with evening exercise program, which has results in increased tol to therapeutic exercise regime and an increase in LE strength. Amb. not attempted to 20 to pt. report of fatigue. Pt. should be able to tolerate short distance ambulation within the next few days.P: Cont. current exercise plan including CPT; emphasize productive coughing techniques; increase strengthening exercises reps to 15; attempt amb. again tomorrow.

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Example 2: Physical Therapy

Goals

1. Pt. will demonstrate productive cough in seated position, 3/4 trials.
2. Pt. will ambulate 150ft with supervision, no assistive device, on level indoor surfaces.

S: Pt. reports not feeling well today, "I'm very tired".

O: Auscultation findings: scattered rhonchi all lung fields. Chest PT was performed in sitting (ant. and post.). Techniques included percussion, vibration, and shaking. Pt. performed a weak combined abdominal and upper costal cough that was non-bronchospastic, congested, and non-productive. The cough/huff was performed with VC. Pectoral stretch/thoracic cage mobilizations performed in seated position. Pt. given towel roll placed in back of seat to open up ant. chest wall. Strengthening exercises in standing - pt. performed hip flexion, extension, and abduction; knee flexion 10 reps x 1 set B. Pt. performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over trach when speaking to prevent infection and explained importance of drinking enough water.

A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been compliant with evening exercise program, which has results in increased tol to therapeutic exercise regime and an increase in LE strength. Amb. not attempted to 20 to pt. report of fatigue. Pt. should be able to tolerate short distance ambulation within the next few days.

P: Cont. current exercise plan including CPT; emphasize productive coughing techniques; increase strengthening exercises reps to 15; attempt amb. again tomorrow.

Tips for Writing Effective SOAP Notes

Here are some best practices to keep in mind when writing SOAP notes:

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• Be Concise and Focused: Keep your notes short and to-the-point, focusing on the most relevant information. Avoid expanding beyond what is required for each section.
• Use Clear and Concise Language: Avoid using slang, poor grammar, or odd abbreviations. Use language common to the field of mental health and family therapy.
• Be Objective and Factual: Avoid personal judgments, value-laden language, and opinionated statements.
• Be Specific and Measurable: Use measurable terms to describe objective findings and treatment goals.
• Write Legibly: If writing by hand, ensure your notes are legible.
• Proofread Your Notes: Always review your notes for accuracy, spelling, and grammar.
• Consider How the Patient is Represented: Avoid using words like “good” or “bad” or any other words that suggest moral judgments.
• Use Language That is Culturally Sensitive.
• When Quoting a Client, be Sure to Place the Exact Words in Quotation Marks.
• Write Your Note as if You Were Going to Have to Defend Its Contents.

Adapting the SOAP Note Format

While the SOAP format is widely used, some clinicians find it helpful to adapt the order to better suit their needs. One such adaptation is the APSO format (Assessment, Plan, Subjective, Objective), which places the most relevant information for ongoing care at the beginning of the note.

Another adaptation is SOAPE, with the letter E as an explicit reminder to assess how well the plan has worked.

The Role of AI in SOAP Note Creation

AI scribes are becoming the fastest way to get SOAP notes done. Like any medical scribe, these tools listen in the background to transcribe and write notes in SOAP format. These tools can listen in the background to transcribe and write notes in SOAP format.

The Patient's Role in the SOAP Note Process

As a patient, understanding the SOAP note process can empower you to be a more active participant in your healthcare. Here's how:

1. Know Your Body: Before your appointment, try to articulate your subjective experiences. What symptoms are you experiencing? When did they begin? Have there been changes over time? Your insight into your body is a crucial piece of the puzzle for your healthcare team.
2. Come Prepared with Your Data: Have relevant medical history handy, such as current medications, allergies, recent lab results, or records from other healthcare providers.
3. Engage in the Assessment: Feel free to ask questions about potential diagnoses or treatment plans.
4. Be Part of Your Plan: Make sure you understand and agree with your care plan. If a certain treatment seems incongruous with your values or lifestyle, speak up. Your healthcare provider can help tailor a plan that best suits your needs and circumstances.

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