SOAP notes are in-depth assessment summaries. A SOAP note is a physical exam report format that may include subjective, objective, assessment, and plan portions.
The SOAP note format provides a uniform method for reporting patient information for quality assessment and improving patient care.
It refers to the patient’s report or chief complaint. The patient’s words are included here. They narrate their feelings, experiences, symptoms, family history, and social history. This is the most essential part of a SOAP note. It is the foundation upon which the rest of the report will be built.
This part of a SOAP note is also known as the subjective portion. Note-taking is very crucial at this point because healthcare providers need relevant information for proper diagnosis. This portion contains the following information:
|• History of present illness (HPI)|
• Social history (SH)
• Family history (FH)
• Review of systems (ROS)
These sections are usually coupled together. For instance, the HPI would include the social history, family history, and review of systems.
If the patient does not describe their symptoms specifically (e.g., “I feel dizzy”), the healthcare provider records that lack of clarity. This recording is done within the findings of the subjective and objective portions.
Example of a subjective report
|A chief complaint of pain in the right side of the face that started about six hours ago.|
The pain is unrelenting and is affecting his sleep. Pain is sharp and constant, with no position or food that makes it better or worse. He also has some trouble with speech.
Pt: States patient has been on antibiotics for sinus infection about a week ago and steroid nasal spray two days ago for a postnasal drip.
He has a history of depression, diagnosed about two years ago and is also on an antidepressant medication.
SH: The patient is married with two children. He works as an accountant.
FH: Father died about ten years ago from a heart attack. Mother has diabetes.
ROS: States that are no other problems at this time. There is no history of allergies, asthma, or skin conditions.
At this stage, the medical professional examines the patient to get an unbiased opinion of the patient’s condition. The findings are documented here. The objective portion is broken into the following components:
|• Vital signs|
• Physical exam
• Medical history
• Physical finding
Vital signs (VS)
VS refers to the patient’s vital signs, summarized into four basic measurements: height, weight, blood pressure (BP), and pulse.
This section also contains other physical assessment measurements such as waist circumference, temperature, and respiratory rate.
Documentation: The patient’s weight is 60 kg. The temperature is 36.3°C. Blood pressure is 120/80 mmHg. Respiratory rate is 16 breaths/minute with mild accessory muscle use.
At this point, the medical professionals can begin to make their assessment and diagnosis.
Physical exam (PE)
The medical professional will perform a physical exam on the patient. This includes subjective and objective measurements of different body parts. They include vitreous humor (in the eye), laryngoscopy (in the throat), palpation (of body parts like the thyroid or liver). The results of the exams inform the health professionals’ clinical reasoning.
Documentation: Patient in no acute distress. Speech is slurred but not dysarthric. There are no abnormalities in the fundi, according to the ophthalmoscopic exam. The neck is supple, with no lymphadenopathy. Lungs are clear to auscultation bilaterally.
Heart sounds are normal, regular, without murmurs. The abdominal exam is soft and non-distended, with no organomegaly or mass. Extremities are warm and well perfused. No edema is present in the lower or upper extremities. For this patient, the doctor is looking for the cause of facial pain.
Medical history (MH)
It is the point where the patient’s medical record is used to help make the diagnosis. For instance, if this patient has depression, the doctor would probably look for signs of infection. This examination will rule out any other possible causes of the current sickness.
Documentation: The patient has no prior medical history of note.
Note that the patient’s “medical history” is described in the subjective section. A medical history typically describes past illnesses, accidents, hospitalizations, surgeries, etc.
Physical finding (PF)
The physical finding section is where the objective findings are described in an organized manner. For example, if a patient complains of jaw pain, the doctor would find the details in this section.
Documentation: There is tenderness on palpation of the right jaw, with no swelling or erythema. The mouth opening is 0-5 cm with pain at 2-5 cm, and the range of motion is 10 degrees forward and 10 degrees right.
Diagnosis: Unilateral myofascial pain of the masseter muscle in the right jaw.
Differential diagnosis: Bacterial infection, dental abscess, arthritis of the joint.
The patient is diagnosed with myofascial pain of the masseter muscle. The doctor lists possible differential diagnoses that may also be present.
The medical professional concludes what is wrong with the patient. This section can be thought of as the “diagnosis” portion written in the patient’s medical record.
Assessment is also where important risk factors are identified. For example, if a patient has severe chest pain, the doctor would list important risk factors such as smoking. They will also include a heart attack history, if any.
Documentation: The patient self-reports pain in the jaw after one day of extreme clenching: no recent head trauma or loss of consciousness. Jaw pain worsened after palpation to anterior teeth and soft palate.
Patient reports being a smoker of twenty years. Medical history is notable for hypertension and depression, which a primary care physician has diagnosed.
The patient’s jaw pain is related to clenching, worsened when palpating certain teeth and soft palate. There are no recent head traumas or loss of consciousness.
In this section, the medical professional will write a plan for proceeding with tests and treatment. In most cases, the patient’s primary care physician will write up a plan, but this could also be completed by the physician in charge of the patient. The plan includes not only what should be done but also when it should be done.
Documentation: The patient will have a consult with endodontics to rule out root canal infection. The patient will follow up with a primary care physician in one week to evaluate possible myofascial pain syndrome.
A Step-by-step Process of Writing a SOAP Note
|1. Presenting complaint|
2. Past medical history
3. Review of systems
4. Physical examination.
5. Diagnosis with a plan for future treatment
6. Discharge summary
7. Follow up information
8. Letter to other healthcare providers if needed
Examples of SOAP Notes
“Patient states that she is a 32-year-old female who has been experiencing mild lower back pain. The patient reports that the pain began at her last doctor’s appointment.
She has not lost consciousness or fallen recently and denies any trauma to the back region. There is no previous medical history of note. The patient reports that she had a hysterectomy six years ago for heavy menstrual bleeding. She is a non-smoker and takes no medications.
She denies any fever, chills, or nausea.
The patient reports that the pain is worse with prolonged standing, walking, or coughing.
The patient reports that she has no allergies.
Physical exam shows tenderness over the lower back that increases with palpation and coughing. There is no erythema, warmth or swelling noted. The patient has a full range of motion in the back. The patient does have decreased range of motion in the right hip area, without pain or erythema.”
The patient will continue treatment with ibuprofen.
“Patient is a 50-year-old male who reports that his pain began approximately four weeks ago. He states that the pain is worse at night and wakes him up at around 3 am. He reports that the pain is slightly relieved by sitting in a recliner with his feet elevated.
The patient reports that he has not lost consciousness or had any falls recently. No fever, chills, or nausea have been reported.
He denies any injury to the back region. There is no previous medical history of note. The patient reports that he does not take any medications.
He is allergic to codeine and sulfonamide antibiotics.
Physical exam shows tenderness over the lower right back that increases with palpation. There is no erythema, warmth or swelling noted. The patient has a full range of motion in the back and no pain with rotation of the right shoulder. Examination of the hip area shows a decreased range of motion without pain or erythema.”
The patient will continue treatment with pain medications and physical therapy.
“Patient is a 65-year-old female who reports that she has been experiencing mild mid-sternal chest pain on the right side over the past two days. She first noticed the pain when coughing during dinner.
She has not had any loss of consciousness or episode of palpitations. She denies any trauma to the chest area.
The patient denies any fever, chills, or nausea. There is no previous medical history of note.
The patient reports that she takes thyroid medication and has an IUD.
The patient denies any allergies.
Physical exam shows normal vital signs with no murmurs, rubs, or gallops noted on cardiac exam. There is no erythema or swelling noted. The patient has a full range of motion in her neck and back with mild stiffness in the thoracic area.”
The patient will continue treatment with ibuprofen and follow up with her internal medicine specialist in five days.
The patient is a ten-year-old male who presents to the walk-in clinic with complaints of mild left flank pain that began approximately 4 hours ago. There is no known trauma to the flank region.
The patient has not lost consciousness or had any falls recently. The patient reports no fever, chills, or nausea. He denies taking any medications.
The patient has no allergies and takes no medication.
Physical exam shows normal vital signs without a murmur noted on cardiac exam. There is no erythema or swelling noted. The patient has a full range of motion in his back without any painful maneuvers.”
The patient will follow up with his primary care physician in one week if the pain is still present.
The patient is a 3-years old girl who presents to the emergency department with complaints of 3 days of abdominal pain. There is no known trauma to the abdomen or any sick contacts.
The patient has a fever and chills. She has had no recent vomiting or diarrhea. There is no known ingestion of toxins.
The patient denies any previous surgeries and reports taking no medications.
Physical exam shows mild tenderness over the abdomen with no rebound pain or guarding present. There is no erythema or mass noted.”
The patient will undergo a lower GI series and follow up with her pediatrician in one week if the results are negative for inflammatory or infectious etiologies.”
The patient is a 35-year old female who presents to the emergency department after sustaining an injury at work.
The patient reports that she has had constant pain over the back of her right shoulder for four months. She denies any trauma to the region or falls. She reports that the pain is ongoing and has not changed over time.
There has been no known use of steroids or NSAIDS within the past month. There are no known allergies to medications.
Physical exam shows general weakness in the right shoulder with decreased range of motion and pain with abduction. There is no erythema or warmth noted.”
The patient will be referred to a specialist for further evaluation and treatment of the shoulder pain.
Characteristics of a Good SOAP Note
Medical practitioners disagree on what makes a good SOAP note, but some common characteristics are consistent across most opinions.
All the components of the SOAP note should be organized logically. Clear headings should be used to navigate between sections, with information written to be identified and located quickly.
SOAP notes should be written in clear, concise language. Clinicians should avoid jargon and abbreviations as much as possible.
SOAP notes should be unbiased and free of assumptions. The medical professional should report what was observed and what tests were done. They shouldn’t conclude on their own.
SOAP notes should be written objectively, without skewed input from the patient or anyone else. This is to prevent bias and errors in memory. Sometimes patients will present a biased report due to their current situation. However, the medical professional should remain objective in writing the SOAP to achieve an accurate diagnosis.
SOAP notes should be specific and thorough but not excessively long. Clinicians should stick to the main points while providing additional detail when needed. Even when a patient insists on particular details that they consider important, the doctor should filter.
SOAP notes should focus on the patients and their specific needs, not be limited by the medical professional’s personal preferences. This focus helps the record have a clear purpose and improve communication across medical professionals.
Using a standard template or format for SOAP notes can help avoid errors in documentation. A standardized template can improve accuracy, legibility, and readability across different medical professionals.
SOAP notes should be written with the patients in mind, so they are easy to read. This means including simple declarative sentences and avoiding jargon. Readability is essential if the note is communicated electronically.
What are the Benefits of Writing Soap Notes?
SOAP notes allow medical professionals to:
- Provide relevant and concise information about the patient in a systematic and logical order.
- Receive feedback from their peers, supervisors, and other medical professionals about their documentation.
- Differentiate between similar-sounding diagnoses and indicate how they are different or similar to each other.
- Receive specific guidance on the correct way to complete a task.
- Provide documentation of the patient’s history and medical status over time.
- Be aware of all the information they are required to document.
- Receive feedback on their documentation so they can improve.
- Prepare themselves for a patient’s future appointments.
- Update other medical professionals about a patient’s condition or treatment.
- Keep track of the relevant information about each patient they treat.
- Communicate with other medical professionals about their patients without having to provide excessive detail.
- Clarify their thoughts and ideas, as well as those of their colleagues.
- Provide a copy of the SOAP note to the patient and other medical professionals.
SOAP notes can benefit patients by:
- Helping them communicate their symptoms and medical history to different doctors and nurses.
- Providing them with a summary of the questions they need to ask their doctor or nurse.
- Letting them know how they can get in touch with medical providers if they have questions or concerns.
- Helping them understand their condition and treatment plan.
- Assisting their family to understand their condition and treatment plan.
- Helping them remember what information to bring with them to appointments and treatments.
- Assisting their doctor in assessing whether they are responding well to treatment.
Writing SOAP notes is a critical step in effective medical documentation and communication. SOAP notes can benefit everyone involved: patients, their families, and the medical professionals who treat them.