How to Write a Soap Note

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Healthcare workers use Subjective, Objective, Assessment, and Plan (SOAP) notes to relay helpful and organized information about patients between professionals. SOAP notes get passed along to multiple people, so be clear and concise while you write them. By listing accurate information and informed diagnoses, you can help a patient get the best care!

Writing the Subjective

• The Subjective section of your soap note is about what the patient is experiencing and how they are handling their concerns.
• Some common examples may include chest pain, decreased appetite, and shortness of breath.
• You can also talk to a family member or spouse to get any necessary information.
• Reader Poll: We asked 268 wikiHow readers who've asked patients about their medical history, and 46% of them agreed that the best way to make them feel at ease is by practicing active listening.[Take Poll]

Tip: If the patient lists multiple symptoms, pay attention to what they describe with the most detail to get an idea of what the most concerning problem is.

• Onset: when did the CC start?
• Location: where is the CC?
• Duration: how long has the patient been affected by the CC?
• Characterization: how does the patient describe the CC?
• Alleviating or Aggravating factors: does anything make the CC feel better or worse?
• Radiation: is the CC in a single location or does it move?
• Temporal patterns: Does the CC occur at specific periods of time?
• Severity: On a scale of 1-10, with 10 being the worst, how does the CC feel?

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• Only write down the details that are important to your current patient. Don’t include full medical histories for relatives if they aren’t relevant.

• For example, you may write: Ibuprofen 200mg orally every 6 hours for 3 days.

Taking the Objective

• The Objective section of the SOAP note refers to data that you collect and measure from the patient.

• For example, instead of writing, “stomach pain,” you would write something like, “abdominal tenderness when pressure applied.”

Tip: Try taking notes on a separate sheet rather than putting them directly in your SOAP note. That way, you can organize the notes more.

• Include printouts of any lab data or photos from the lab tests so other medical professionals can see them first hand.

Making an Assessment

• For example, if you had previously prescribed an antibiotic, you may record how the affected area has less swelling.

List the patient’s problems in order of importance. If the patient listed multiple concerns, start organizing them with the most severe on top and the least severe at the end. If you have trouble determining which problem is the most severe, ask them what they’re the most concerned with.

• You may not know exactly what’s causing the problems, so make educated guesses based on what you’ve already found.

Tip: Look for a diagnosis that covers multiple problems if you can. Be sure to list if any of the problems could interact with one another.

• Always leave a description so other professionals know why you made certain decisions with your treatment.

Creating a Plan

• For example, you may need to perform an X-ray or CT scan to determine if there are more causes for underlying pain.
• List what should be done after special tests whether they come back positive or negative.

• Sometimes, you may need to perform surgery depending on the severity of the concern.

Include any referrals to specialists if needed. If the type of care the patient needs is not your specialty, then include references for who to reach out to next. Provide names for all of the diagnoses if you still are narrowing down the cause. Let the patient know what the next steps are so they can stay informed.

Formatting Your SOAP Note

• For example, you may write, “45-year-old female presenting with abdominal pain,” as the first step in your SOAP note.

• There is no required format or length for the content in your SOAP note as long as it follows the Subjective-Objective-Assessment-Plan order.

Tip: Make sure any abbreviations or medical terms you use are easy to understand so they don’t cause any confusion.

Write or type the SOAP note depending on what your workplace prefers. Many systems in clinics have secure forms you can fill out on your computer so the information can be passed around quickly. However, your workplace may require you to take SOAP notes by hand. Make sure you follow the format your workplace uses closely so it stays organized. [11] X Research source

Community Q&A

This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.

The O can stand for either “objective” or “observations.” This section of the note covers objective data that you observe during the examination or evaluation of the patient (e.g., their vital signs, laboratory results, or measurable information like their range of motion during an exam).

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This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.

A good SOAP note should be concise, professional in tone, and specific. Avoid anything that sounds judgmental or overly positive or negative toward the patient. Review the language to make sure it’s clear (e.g., check your pronouns to make sure they aren’t confusing and it’s clear who/what you’re referring to).

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This answer was written by one of our trained team of researchers who validated it for accuracy and comprehensiveness.

A variety of healthcare professionals use SOAP notes to help them assess their patients. This can include doctors, counselors, physical therapists, and emergency medical technicians. SOAP notes are especially helpful for sharing information between different providers who are treating the same patient.

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There are no length requirements or limitations for a SOAP note. Just be sure all of the information is present and easy to read.

Always keep your sections organized so you don’t confuse anyone else who’s reviewing the patient’s charts.

Avoid using too many acronyms or abbreviations while writing your SOAP note since it could be confusing to others looking at it. [12] X Research source

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1. ↑https://www.simplepractice.com/resource/how-to-write-soap-notes/
2. ↑https://chpgroup.com/evidence-in-ih/best-practices-the-anatomy-of-a-soap-note/
3. ↑https://chpgroup.com/evidence-in-ih/best-practices-the-anatomy-of-a-soap-note/
4. ↑https://www.simplepractice.com/resource/how-to-write-soap-notes/
5. ↑https://www.simplepractice.com/resource/how-to-write-soap-notes/
6. ↑https://www.ncbi.nlm.nih.gov/books/NBK482263/
7. ↑https://www.ncbi.nlm.nih.gov/books/NBK482263/
8. ↑https://www.ncbi.nlm.nih.gov/books/NBK482263/
9. ↑https://www.ncbi.nlm.nih.gov/books/NBK482263/

1. ↑https://www.aresearchguide.com/write-a-soap-note.html
2. ↑https://www.aresearchguide.com/write-a-soap-note.html
3. ↑https://www.aresearchguide.com/write-a-soap-note.html

About This Article

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

A SOAP note, or a subjective, objective, assessment, and plan note, contains information about a patient that can be passed on to other healthcare professionals. To write a SOAP note, start with a section that outlines the patient's symptoms and medical history, which will be the subjective portion of the note. After that section, record the patient's vital signs and anything you gather from a physical exam for the objective section. To write the assessment portion of the note, write down any diagnoses you can make and why you chose them. Finish your note with the plan section, which should include any tests, therapies, and medications you think the patient should try. For tips on how to format a SOAP note, scroll down!