Understanding SOAP Notes
SOAP is a structured documentation method used by healthcare providers worldwide
S - Subjective
Patient's reported symptoms, concerns, and history
Examples:
- • Chief Complaint: 'I've been having chest pain for 2 days'
- • History of Present Illness: Pain started suddenly, 7/10 severity, radiates to left arm
- • Review of Systems: Denies shortness of breath, nausea, or dizziness
O - Objective
Observable and measurable clinical findings
Examples:
- • Vital Signs: BP 140/90, HR 88, RR 16, Temp 98.6°F, O2 Sat 98%
- • Physical Exam: Alert, oriented x3, no acute distress
- • Cardiovascular: Regular rate and rhythm, no murmurs
A - Assessment
Clinical impression and differential diagnosis
Examples:
- • Primary Diagnosis: Chest pain, likely musculoskeletal (ICD-10: R06.02)
- • Differential Diagnosis: Rule out acute coronary syndrome
- • Secondary Diagnoses: Hypertension (controlled), Type 2 DM (controlled)
P - Plan
Treatment plan and follow-up instructions
Examples:
- • Medications: Continue current medications, add ibuprofen 400mg TID PRN
- • Diagnostic: EKG completed (normal), consider stress test if symptoms persist
- • Patient Education: Discussed chest pain warning signs, when to seek emergency care
Complete SOAP Note Template
Copy and customize this template for your practice
SOAP Note Template
SUBJECTIVE:
Chief Complaint: [Patient's main concern in their own words]
History of Present Illness: [Detailed description of current symptoms]
Review of Systems: [Relevant positive/negative findings]
Past Medical History: [Relevant medical history]
Medications: [Current medications and dosages]
Allergies: [Known allergies and reactions]
Social History: [Relevant social factors]
OBJECTIVE:
Vital Signs: BP ___ HR ___ RR ___ Temp ___ O2 Sat ___
General Appearance: [Overall patient presentation]
Physical Examination:
• HEENT: [Head, eyes, ears, nose, throat findings]
• Cardiovascular: [Heart examination findings]
• Respiratory: [Lung examination findings]
• Abdomen: [Abdominal examination findings]
• Neurological: [Neurological examination findings]
Diagnostic Results: [Lab results, imaging, etc.]
ASSESSMENT:
Primary Diagnosis: [Main diagnosis with ICD-10 code]
Differential Diagnosis: [Alternative diagnoses considered]
Secondary Diagnoses: [Additional relevant diagnoses]
Clinical Impression: [Overall clinical assessment]
PLAN:
Medications: [Prescribed medications with dosages]
Diagnostic Tests: [Ordered tests or procedures]
Patient Education: [Information provided to patient]
Follow-up: [Next appointment or monitoring plan]
Referrals: [Specialist referrals if needed]
Return Precautions: [When to seek immediate care]
SOAP Note Examples by Specialty
Real-world examples from different medical specialties
Primary Care Example
Subjective:
45-year-old male presents with 3-day history of productive cough and fever. Reports fatigue and decreased appetite. No recent travel or sick contacts.
Objective:
Vital signs: T 101.2°F, BP 128/82, HR 92, RR 18, O2 Sat 96%. Physical exam reveals crackles in right lower lobe, otherwise unremarkable.
Assessment:
Community-acquired pneumonia, right lower lobe (ICD-10: J18.9)
Plan:
Azithromycin 500mg daily x 5 days, supportive care, return if worsening, chest X-ray in 6 weeks to confirm resolution.
Mental Health Example
Subjective:
28-year-old female reports increased anxiety and panic attacks over past 2 weeks. Difficulty sleeping, racing thoughts. Denies suicidal ideation.
Objective:
Alert, cooperative, anxious affect. Speech rapid, thought process organized. No psychotic symptoms. PHQ-9 score: 12, GAD-7 score: 15.
Assessment:
Generalized anxiety disorder with panic attacks (ICD-10: F41.1)
Plan:
Start sertraline 25mg daily, CBT referral, relaxation techniques, follow-up in 2 weeks to assess medication tolerance.
Pediatrics Example
Subjective:
6-year-old brought by mother for ear pain x 2 days. Child reports pain 8/10, difficulty hearing. No fever reported at home.
Objective:
Vital signs stable. Right tympanic membrane erythematous and bulging. Left ear normal. No lymphadenopathy.
Assessment:
Acute otitis media, right ear (ICD-10: H66.91)
Plan:
Amoxicillin 400mg/5ml, 1 tsp BID x 10 days. Pain management with acetaminophen. Return if no improvement in 48-72 hours.
SOAP Note Best Practices
Tips for writing effective and compliant SOAP notes
Do's
- Use objective, professional language
- Include specific measurements and observations
- Document patient's exact words in quotes
- Use standard medical abbreviations
- Include ICD-10 codes for diagnoses
Don'ts
- ✗Use subjective language in objective section
- ✗Include personal opinions or judgments
- ✗Use non-standard abbreviations
- ✗Leave sections blank without explanation
- ✗Copy and paste without reviewing