How to write a SOAP note

Although every practitioner will have their own preferred methods when it comes to writing SOAP notes, there are useful ways that you can ensure you’re covering all the right information. We’ve already covered the type of information that should be covered in each section of a SOAP note, but here are some additional ways that you can guarantee this is done well.

Subjective

As you know, the subjective section covers how the patient is feeling and what they report about their specific symptoms. The main topic, symptom or issue that the patient describes is known as the Chief Complaint (CC). There may be more than one CC, and the main CC may not be what the patient initially reports on. As their physician, you need to ask them as many questions as possible so you can identify the appropriate CC. A History of Present Illness (HPI) also belongs in this section. This includes questions like:

When did the symptoms begin?
When did you first notice the CC?
Where is the CC located?
What makes the CC better?
What makes the CC worse?

Hint 1: It is a good idea to include direct quotes from the patient in this section. Hint 2: When you write the subjective section, you need to be as concise as possible. This may mean compacting the information that the patient has given you to get the information across succinctly.

Objective

The objective section includes the data that you have obtained during the session. This may include:

Vital signs
Laboratory results
X-ray results
Physical exam

Based on the subjective information that the patient has given you, and the nature of their CC, you will respond appropriately and obtain objective data that indicates the signs of the CC. In addition to gathering test/lab results and vital signs, the objective section will also include your observations about how the patient is presenting. This includes their behavior, affect, engagement, conversational skills and orientation. Hint: Confusion between symptoms and signs is common. Symptoms are what the patient describes and should be included in the subjective section whereas signs refer to quantifiable measurements that you have gathered indicating the presence of the CC.

Assessment

It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient’s symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan. If there are a number of different CCs, you may want to list them as ‘Problems’, as well as the responding assessments. The assessment section is frequently used by practitioners to compare the progress of their patients between sessions, so you want to ensure this information is as comprehensive as possible, while remaining concise. Hint: Although the assessment plan is a synthesis of information you’ve already gathered, you should never repeat yourself. Don’t just copy what you’ve written in the subjective and objective sections.

Plan

The final section of a SOAP note covers the patient’s treatment plan in detail, based on the assessment section. You want to include immediate goals, the date of the next session (where applicable) and what the patient wants to achieve between their appointments. You can use the plan in future sessions to identify how much progress the patient has made, as well as making judgments regarding whether the treatment plan requires changing. The plan section may also include:

Referrals to specialists
Patient education
Medications
If further testing is required
Progression or regression made by the client

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How to write a SOAP note