How to Write SOAP Notes? A Comprehensive Guide with Examples

Introduction

SOAP notes are pivotal in healthcare settings and enable healthcare professionals to document in an organized and structured manner, and provide timely reminders regarding specific tasks. The notes serve as a cognitive framework for clinical reasoning, crucial for diagnosing, assessing, treating patients, and tracking health status among professionals. This structured documentation serves as a checklist and index for learning from records.

Understanding the SOAP Format

• Subjective: Gather information reported by the patient, like medical history, current symptoms, and chief complaints, which provides insights into the patient’s concerns and perspectives. 

• Objective: Document objective findings and observations like vital signs, laboratory tests, and physical examination results that provide quantifiable data for clinical assessment. 

• Assessment: Develop a clinical assessment based on subjective and objective information, such as diagnosing the patient’s condition, identifying relevant factors, and considering differential diagnoses. 
• Plan: Develop a comprehensive patient care plan, highlighting treatment goals, scheduling follow-up appointments, prescribing medications or therapies, and providing patient education to support recovery and fitness.

Step-by-Step Guide to Writing SOAP Notes

Subjective:

Document patient’s information accurately:

1. Record their chief complaint.
2. Use the OPQRST method for illness history.
3. Include significant medical, surgical, family, and social history.
4. List current medications with frequency and doses. 

Objective:

Record patient’s objective information:

1. Document vital signs.
2. Perform comprehensive physical exam.
3. Include results of diagnostic tests.
4. Provide clear and concise information. 

Assessment:

Draft patient’s assessment summary:

1. Provide a brief patient summary.
2. Include clinical stability and major diagnosis.
3. Mention multiple major diagnoses if applicable. 
4. Provide differential diagnosis for new symptoms.
5. Ensure completeness and clarity in reporting.

Plan:

Finalize the SOAP note with a plan:

1. List medical problems by severity.
2. Recommend a management plan for each problem. 
3. Include code status, deep vein thrombosis prophylaxis, and disposition for inpatients.
4. View SOAP notes as learning opportunities for obtaining proficiency.

Subjective Section: Gathering Patient Information

Chief Complaint: Encourage patients to voice their main concerns and struggles in their own words. 

Medical History: Acquire their relevant past medical history, family history, surgical history, and social history. 

Current Symptoms: Ask them about current symptoms using the OPQRST method (Onset, provocation, quality, radiation, severity, and time).

Accurate Documentation: Document the patient’s information accurately and objectively in the SOAP note.

Objective Section: Documenting Observations and Findings

Vital Signs: Document the patient’s temperature, blood pressure, heart rate, oxygen saturation and respiratory rate. 

Physical Examination: Perform a comprehensive physical exam consisting of head-to-toe assessments.  

Laboratory Tests: Include results of laboratory tests, imaging studies, and diagnostic procedures. 

Clear and Concise: Document objective findings clearly and concisely using standardized terminology.

Assessment Section: Formulating a Clinical Assessment 

Data Integration: Observe subjective and objective information to form a clinical assessment. 

Diagnosis: Analyze the patient’s condition based on collected data and clinical reasoning. 

Relevant Factors: Consider factors like risk factors, additional medical conditions, and patient preferences. 

Possible Diagnoses: List any possible diagnoses based on the presented findings and symptoms. 

Plan Section: Developing a Care Plan

Treatment Goals: Establish clear and measurable treatment goals in collaboration with the patient.

Medications and Therapies: Prescribe appropriate medications and therapies according to the patient’s diagnosis and needs. 

Follow-up Appointments: Schedule follow-up appointments to monitor your patient’s progress and adjust their treatment plan accordingly. 

Patient Education: Offer patient education on treatment plans, diagnosis, and self-care strategies.