SOAP note

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.

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Components

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status (e.g., it will often be noted whether the patient has passed gas, because if they have, it is considered by many physicians to be safer to allow them to eat.)

Subjective component

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. Pertinent Medical history, surgical history, family history, social history along with current medications and allergies are also recorded.

Objective component

Includes vital signs, findings from physical examinations Eg posture, bruising, abnormalities, and results from laboratory tests.

Assessment

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.

Plan

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 groups together.

An example

A very rough example follows for a patient being reviewed following an appendectomy:

S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus.

O: [Vital signs, lab data, and physical exam results would be recorded here.]

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