Physician SOAP Notes
What Does SOAP Stand For?
— The initial portion of the SOAP note format consists of subjective
observations. These are symptoms the patient verbally expresses or as stated by
a significant other. These subjective observations include the patient's descriptions
of pain or discomfort, the presence of nausea or dizziness, when the problem first
started, and a multitude of other descriptions of dysfunction, discomfort, or illness
the patient describes.
— The next part of the format is the objective observation.
These objective observations include symptoms that can actually be measured, seen,
heard, touched, felt, or smelled. Included in objective observations are vital signs
such as temperature, pulse, respiration, skin color, swelling and the results of
— Assessment follows the objective observations. Assessment
is the diagnosis of the patient's condition. In some cases the diagnosis may be
clear, such as a contusion. However, an assessment may not be clear and could include
several diagnosis possibilities.
— The last part of the SOAP note is the health care provider's plan.
The plan may include laboratory and/or radiological tests ordered for the patient,
medications ordered, treatments performed (e.g., minor surgery procedure), patient
referrals (sending patient to a specialist), patient disposition (e.g., home care,
bed rest, short-term, long-term disability, days excused from work, admission to
hospital), patient directions (e.g. elevate foot, RTO 1 week), and follow-up directions
for the patient.
What IS a SOAP Note?
The SOAP note format is used to standardize medical evaluation entries made in clinical
records. The SOAP note is written to facilitate improved communication among all
involved in caring for the patient and to display the assessment, problems and plans
in an organized format. Many Electronic Health Records (EHR) systems are capable
of producing SOAP Notes. The actual notes and other information contained within
the EMR are commonly referred to as Electronic Medical Records or EMRs.
Here's more information on EHRs
Components of a SOAP Note?
The four components of a SOAP note are S
lan. The length and focus of each component of a SOAP note varies depending
on the specialty; for instance, a surgical SOAP note will generally be much briefer
than a psychiatric SOAP note, and will focus on issues that relate to post-surgical
This describes the patient's current condition in narrative form. The history or
state of experienced symptoms are recorded in the patient's own words.
It will include all pertinent and negative symptoms under review of body systems
in addition pertinent medical history, surgical history, family history, social
history along with current medications and allergies are also recorded.
A SAMPLE history is one method of obtaining this information from a patient.
If this is the first time a doctor is seeing a patient, they will take a History
of Present Illness or HPI. To structure this portion of the note,
you can use another mnemonic: OLD CHARTS, as in what would you find if you looked
at the patient's "old chart"
- CHaracter (sharp, dull,
- Alleviating/Aggravating factors
- Temporal pattern (every
morning, all day, etc)
- Symptoms associated
The objective component includes:
- Vital signs
- Findings from physical examinations, such as posture, bruising, and abnormalities
- Results from laboratory tests
- Measurements, such as age and weight of the patient.
Is a quick summary of the patient with main symptoms/diagnosis including a differential
diagnosis, a list of other possible diagnoses usually in order of most likely to
least likely. When used in a Problem Oriented Medical Record, relevant problem
numbers or headings are included as subheadings in the assessment.
What is a Problem Oriented Medical Record
A Problem Oriented Medical Record (POMR), a method
of recording data about the health status of a patient in a problem-solving system.
The POMR preserves the data in an easily accessible way that encourages ongoing
assessment and revision of the health care plan by all members of the health care
The particular format of the system used varies from setting to setting, but the
components of the method are similar. A data base is collected before beginning
the process of identifying the patient's problems. The data base consists of all
information available that contributes to this end, such as that collected in an
interview with the patient and family or others, that from a health assessment or
physical examination of the patient, and that from various laboratory and radiologic
It is recommended that the data base be as complete as possible, limited only by
potential hazard, pain or discomfort to the patient, or excessive assumed expense
of the diagnostic procedure. The interview, augmented by prior records, provides
the patient's history, including the reason for contact; an identifying statement
that is a descriptive profile of the person; a family illness history; a history
of the current illness; a history of past illness; an account of the patient's current
health practices; and a review of systems.
The physical examination or health assessment makes up the second major part of
the data base. The extent and depth of the examination vary from setting to setting
and depend on the services offered and the condition of the patient.
The next section of the POMR is the master problem list.
The formulation of the problems on the list is similar to the assessment phase of
the nursing process. Each problem as identified represents a conclusion or a decision
resulting from examination, investigation, and analysis of the data base. A problem
is defined as anything that causes concern to the patient or to the caregiver, including
physical abnormalities, psychologic disturbance, and socioeconomic problems. The
master problem list usually includes active, inactive, temporary, and potential
problems. The list serves as an index to the rest of the record and is arranged
in five columns: a chronologic list of problems, the date of each problem's onset,
the action taken, the outcome (often its resolution), and the date of the outcome.
Problems may be added, and intervention or plans for intervention may be changed;
thus the status of each problem is available for the information of all members
of the various professions involved in caring for the patient.
The third major section of the POMR is the initial plan, in which each separate
problem is named and described, usually on the progress note in
a SOAP format: S, subjective data from the patient's point of view; O, the objective
data acquired by inspection, percussion, auscultation, and palpation and from laboratory
and radiologic tests; A, assessment of the problem that is an analysis of the subjective
and objective data; and P, the plan, including further diagnostic work, therapy,
and education or counseling. After an initial plan for each problem is formulated
and recorded, the problems are followed in the progress notes by narrative notes
in the SOAP format or by flow sheets showing the significant data in a tabular manner.
A discharge summary is formulated and written, relating the overall assessment of
progress during treatment and the plans for follow-up or referral. The summary allows
a review of all the problems initially identified and encourages continuity of care
for the patient.
This is what the health care provider will do to treat the patient's concerns. This
should address each item of the differential diagnosis. A note of what was discussed
or advised with the patient as well as timings for further review or follow-up may
also be included. Often the Assessment and Plan sections are grouped together.
SOAP notes facilitate better medical care when used in the patient's record
and provide for far greater review and quality control. SOAP Note Documentation
of patient complaints and treatment should be consistent,
concise and comprehensive.
The SOAP note
is not meant to be as detailed as a Progress Report. Partial
sentences and abbreviations are appropriate. However, care should be exercised based
on how the abbreviations are used as they can differ for each specialty. The length
of the note will differ for each specialty as well.
can be flexible and different care providers will often have their
own styles as well as different office will have thier preferences. Usually SOAP
written by the uninitated will usually be a little longer than those
of more advanced staff with more clinical judgment and experience in proper SOAP
note writing format. A short, precise SOAP note is often better than an entry that
is too verbose.
Documenting patient encounters in the medical record is an integral part of practice
workflow. Additionally, Prehospital care providers such as EMTs may use the same
or similar format to communicate patient information to Emergency department personell.
Very rough example for a patient being reviewed
following an appendectomy (resembles a surgical SOAP note).
Surgery Service, Dr. Jones
S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient
O: Afebrile, P 84, R 16, BP 130/82. No acute distress. Neck no JVD, Lungs
clear Cor RRR Abd Bowel sounds present, mild RLQ tenderness, less than yesterday.
Wounds look clean. Ext without edema
A: Patient is a 37 year old man on post-operative day 2 for laparoscopic
appendectomy, recently passed flatus.
P: Recovering well. Advance diet. Continue to monitor labs. Prepare for discharge
home tomorrow morning.
Note that the plan itself includes various components:
Diagnostic component - continue to monitor labs
Therapeutic component - advance diet
Patient education component - that is progressing well
Disposition component - discharge to home in the morning