How to write a SOAP note
SOAP notes are used in medical charts to provide a comprehensive and standardized documentation of a patient's visit, and are used by healthcare providers for effective communication and coordination of care.
In this post:
I. What is a SOAP note?
A SOAP note is a method of documentation used by healthcare providers, including PAs, physicians and nurses, to write down information about a patient's condition.
It is an acronym that stands for:
Subjective: This section includes the patient's own description of their symptoms and complaints.
Objective: This section includes observations and data gathered by the healthcare provider, such as vital signs, physical examination findings, and test results.
Assessment: This section includes the healthcare provider's evaluation of the patient's condition, including a diagnosis or differential diagnosis.
Plan: This section includes the healthcare provider's recommendations for treatment, management, and follow-up.
II. What should a good SOAP note covey?
A good SOAP note should be easily understood by other healthcare providers who may be involved in the patient's care, and should provide a complete and accurate picture of the patient's condition and care. This includes:
A clear and concise description of the patient's presenting symptoms and complaints, as well as any relevant history.
Objective findings from the physical examination and any relevant tests or procedures.
An assessment of the patient's condition, including a diagnosis or differential diagnosis.
A clear and concise plan for treatment, management, and follow-up, including any medications or referrals.
Additionally, a good SOAP note should be legible, organized, and formatted in a consistent and standardized manner, to ensure effective communication and coordination of care.
III. SOAP Note Examples
Here's an example of a fictional SOAP note for a patient presenting with a headache:
a) SOAP note in a narrative form:
“Subjective: The patient reports a headache that started this morning. The pain is described as a constant, dull ache on the front and sides of the head, with no obvious trigger. The patient reports a decreased appetite and difficulty concentrating, but denies any nausea or vomiting.
Objective: Vital signs are within normal limits. Physical examination reveals tenderness upon palpation of the temples and frontal regions, but no obvious signs of inflammation or trauma.
Assessment: 28 y/o F presents with tension headache.
Plan: The healthcare provider recommends over-the-counter ibuprofen, rest, and stress management techniques. The provider also schedules a follow-up appointment in two weeks to assess the patient's response to treatment”
b) SOAP note in jot note format:
Subjective:
Headache started this morning
Described as constant, dull ache on front and sides of head
No obvious trigger
Decreased appetite and difficulty concentrating
No nausea or vomiting
Objective:
Vital signs within normal limits
Tenderness upon palpation of temples and frontal regions
No obvious signs of inflammation or trauma
Assessment:
28F with Tension headache
Plan:
Over-the-counter ibuprofen
Rest
Stress management techniques
Follow-up appointment in 2 weeks.
Family Medicine SOAP Outpatient Progress Note
Patient ID: 35F, otherwise healthy, from home
Subjective: The patient is a 35-year-old female who presents with a sore throat for the past 4 days. She reports that the cough is productive with greenish sputum and the sore throat is painful and makes it difficult for her to eat and drink. She denies any shortness of breath but does report body aches, nausea, and decreased appetite. There is no cough. The patient reports a history of seasonal allergies but no history of pneumonia or bronchitis.
Objective:
BP: 120/80 mmHg, HR: 72 bpm, RR: 18, Temp: 38.3°C
The patient is alert and oriented. Oral mucosa is moist with white patches visualized on throat. Neck palpation demonstrates swollen and tender lymph notes. Petechiae on palate. Lung exam reveals clear breath sounds bilaterally with a few ronchi heard in the left lower lobe. Throat is erythematous and swollen with exudates present on the tonsils. Abdomen is soft, and non-tender.
Rapid strep test done today is positive.
Assessment: 35 female who presents clinically with upper respiratory infection, most likely Streptococcus pharyngitis.
Plan:
Prescribe Amoxicillin 500mg orally three times a day for 10 days for suspected bacterial infection.
CENTOR criteria is 4, therefore a rapid antigen test was performed today, and throat swab for to rule out infectious mononucleiuses
Advise the patient to rest, drink plenty of fluids, and use a humidifier to relieve sore throat symptoms.
Advise the patient to follow up in 3-5 days or sooner if symptoms worsen.
Follow-up: Phone call once results from throat swab return.
Internal Medicine SOAP Inpatient Progress Note
INTERNAL MEDICINE PROGRESS NOTE
ID: 88F admitted for _____
Subjective:
seen at bedside, doing well.
No nausea/vomiting
No SOB, CP
Objective:
BP: ___; HR: ___ ; RR: ___; Temp: ; SaO2: ___;
Assessment:
Plan:
Issue 1;
Issue 2;
Issue 3;
John Smith, PA-S2
Clinical Clerk, Internal Medicine
Staff: Dr. Y.
General Surgery SOAP Inpatient Progress Note
78M admitted for acute SBO, with Hx of Liver Cirrhosis and PSC (LOS: 6 days)
Subjective:
Seen at bedside, drowsy, unarousable. Colicky abdo pain. Prolonged fasting (~12 days) with NG tube, No nausea/vomiting. NG draining light bile, stoma putting out gas and dark liquid contents.
Objective:
Vitals: BP: 110/65; HR: 91 ; RR: 17; Temp: 36.3°C ; SaO2: 95% on RA;
I&O: 1700 cc; Out: 200 (stool); Weight: 60 kg
On Exam: Not alert, even on painful stimuli, Abdomen distended and tympanic, audible moan on exam. No percussion tenderness. Appears sarcopenic.
Abdo XR: further dilatation of small bowel loops compared to previous radiographs. Differential air fluid levels concerning for ongoing mechanical obstruction.
Urinalysis: small leukocytes
Labs: Hb 93 (L), Sodium 148 (H), Bicarbonate 18 (L), Calcium 2.01 (L), Albumin 31 (L), Creatinine 90. Mg 0.86, Glucose 4.8, Potassium 4.1. AST 73 (H), ALT 35, Bilirubin 12, INR 1.2, Lipase 31.
Assessment/Plan:
Altered LOC:
- Septic workup for hypoactive delirium (CXR, CT head, urine & blood cultures), possible meds contributory
- will monitor drowsiness & reassess
- GIM consult to assess for ?SBP, hepatic encephalopathy.Abdo Pain:
Abdo CT scan, with discussion to radiology to rule out developing ischemiaDiet:
Consult Gastroenterology for consideration of TPN.Family:
To recertify goals of care with SDM.
John Smith, PA-S2
Clinical Clerk, General Surgery
Staff: Dr. Y.
Abbreviations in this note:
SBO: short bowel obstruction
PSC: Primary Sclerosing Cholangitis
SDM: substitute decision maker
TPN: total parenteral nutrition
SBP: Spontaneous bacterial peritonitis
Orthopaedic Surgery SOAP Inpatient Progress Note
ORTHOPAEDIC SURGERY PROGRESS NOTE
ID: 75F POD#4 right femur fracture ORIF (DOS: December 27, 20__)
Subjective:
Seen on ward at bedside, doing well. Slight disocmfort.
No nausea/vomiting. SLP is following for difficulty swallowing, NG tube in situ. Had some tongue numbness Saturday but this has resolved, no facial droop or other concerning features.
No SOB, CP. No constitutional symptoms.
Seen by Endo today; spoke with patient’s sister in law (SDM) for goals of care discussion.
Objective:
BP: 145/80; HR: 106 ; RR: 16; Temp: 37 degrees C; SaO2: 97% on room air
On exam:
Alert and oriented.
Dressing is clean, dry, intact. Staples in-situ.
Zimmer in Situ, ROM not assessed today.
Swelling to right calf, compartments soft.
Distally neurovascularly intact to bilateral Lower extremities.
Abdo soft, and non-tender.
Labs:
Hb 92 > 85 (Dec 31) > 80 (Dec 30), Lactate 1.2, Troponin 60 (was 86, continuing to come down, pending repeats), K 3.3, repeat lytes pending.
Assessment: 75F with T2DM admitted for right femur fracture ORIF POD#45, concern for BG control GERD and diet.
Plan:
Activity:
WBAT in LLE, TTWB for RLE, otherwise AAT.
Physiotherapy to see and mobilize.Diet:
SLP cleared patient for clear fluids. SLP will continue to follow.Diabetes:
Followed by Endocrinology; To re-continue Metformin and Sitagliptin, Continue Lantus and low dose NR & free style Libre2 prescription to help with glucose monitoring.GERD:
Continue Pantoloc.
Outpatient referral to Dr. X for management of Acid reflux.DVT prophylaxis:
Enoxparin 40 mg SC PO AM daily.
Discharge DVT prophylaxis TBD.Disposition: Rehab
Follow-up in clinic with Dr. Y in 2 weeks time for repeat x-rays and staple removal.
Jane Smith, PA-S2
Clinical Clerk, Orthopaedic Surgery
Staff: Dr. Y.
Orthopaedic Surgery SOAP Fracture Clinic (Outpatient) Progress Note
FRACTURE CLINIC PROGRESS NOTE
ID: 64F 6 weeks post right distal radius fracture (DOI: January 3, 20__), non-operative management
Subjective:
Today patient reports pain has improved overall. Residual discomfort the dorsum of the left distal radius. No paresthesias. No pain medications. Comfortable in cast and has been NWB with the affected arm. Takes no pain medications.
Objective:
On exam: After cast removal, there is mild swelling to the digits, hand and wrist - decreased from previous. Non-tender on palpation to the distal radius.
Right Wrist ROM: Flexion: 20°; Extension: 30°; Supination: 45°; Pronation: 90°; limited as patient has been in cast immobilization for the past 6 weeks.
APL appears intact with thumb abduction. Axial loading of the wrist is non-painful. Patient is distally neurovascularly intact to median, radial and ulnar nerves. PIN and AIN intact. Radial pulse is palpable. Cap refill < 2 seconds.
Right wrist x-rays: Repeat x-rays today demonstrate less conspicuous fracture lines, with evidence of bony callus formation. No shift in fracture fragments. Ulnar neutral. No change in ulnar styloid fracture. She remains in a good position.
Assessment: 64F progressing well 6 weeks post right distal radius fracture with non-operative management, with radiographic signs of interval bony healing.
Plan:
Cast was removed.
Outfitted with removable splint to be used PRN for support with activities, may discontinue at night for activities.
Physiotherapy script provided to start wrist and finger ROM, grip exercises, and decrease pain and swelling modalities. Gradual strengthening to start in 2-3 weeks. We demonstrated home exercises to work on wrist ROM at home top be done daily at home.
To avoid heavy lifting for another 4-6 weeks. May return to modified, sedentary office duties. Will reassess ability to return to full, unrestricted duties work at next visit.
Follow-up in 6 weeks with new x-rays.
Jane Smith, PA-S1
Clinical Clerk, Orthopaedic Surgery
ABC Hospital - Fracture Clinic
In service of: Dr. Y
Abbreviations in this note:
DOI: date of injury
NWB: non-weightbearing
APL: abductor pollicis longus
ROM: range of motion
AIN: anterior interosseous nerve
PIN: posterior interosseous nerve
PRN: as needed
IV. Tips on writing good SOAP notes
Be concise: Keep your SOAP notes brief and to the point. Avoid unnecessary details or irrelevant information.
Use proper terminology: Use standard medical terminology and abbreviations to ensure consistency and accuracy.
Be objective: Focus on the facts, rather than opinions or interpretations. Record objective findings from the physical examination and any tests or procedures.
Be clear: Ensure that your SOAP notes are clear and easily understood by other healthcare providers. Use plain language, and avoid medical jargon or technical terms that may not be familiar to others. Keep in mind that some patients have access to their electronic records and may reference your notes in case they have forgotten what was discussed during the encounter.
Organize your notes: Use a consistent format for all your SOAP notes, and keep each section concise and focused. Make sure that the subjective, objective, assessment, and plan sections are clearly labeled and easy to find.
Check for accuracy: Before you submit your SOAP notes, make sure to review them for accuracy, clarity, and completeness. Check that all relevant information has been included and that the plan of care is clear and appropriate.
Follow privacy laws: Always ensure that your SOAP notes are compliant with PHIPA privacy laws and regulations, and only include information that is necessary for patient care. Avoid including any confidential or sensitive information that is not relevant to the patient's treatment.
V. Are SOAP notes the same as Consult Notes and Progress Notes?
SOAP notes, consult notes, and progress notes are similar in that they are used to document a patient's care and progress in a healthcare setting, but they have different purposes and focuses.
SOAP notes (Subjective, Objective, Assessment, Plan) are used to document a patient's initial evaluation and subsequent follow-up visits. They typically include a description of the patient's symptoms, objective findings from the physical examination, a diagnosis or assessment of the patient's condition, and a plan for treatment and management.
Consult notes are used to document a consultation between healthcare providers, typically when a specialist is consulted for a specific issue or condition. This incorporates all aspects of a SOAP note (subjective, objective, assessment and plan). They often include a summary of the patient's history, current symptoms, and relevant test results, as well as the specialist's recommendations or opinions.
Progress notes are used to document a patient's progress over time and are typically written after each encounter or visit. This incorporates all aspects of a SOAP note (subjective, objective, assessment and plan). They provide a summary of the patient's status, any changes in symptoms or treatment, and a plan for ongoing care. Progress notes may also include updates from other healthcare providers, such as results of tests or treatments.
Final notes
Go back and reference your notes from PA school about how to write a SOAP note! Keep in mind on each clinical rotation, different preceptors will have different expectations on what an ideal SOAP note should look like.
References
Podder, V., Lew, V., & Ghassemzadeh, S. (2022) SOAP Notes. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing
Sindhu, K. (2020) What are SOAP Notes? Expert Insights. Wolters Kluwer, Lippincott Medicine.
