The SOAP Note Format

The letters SOAP is an acronym. The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE,
ASSESSMENT and PLAN. Many medical offices use the SOAP note format to standardize
medical evaluation entries made in patient records. The SOAP note improves communication
beween all caring for the patient. It displays the assessment, problems and plans in an organized
format and facilitates better medical care when used.

SOAP Note Documentation

Medical documentation of patient complaint(s) and treatment must be consistent, concise and
comprehensive. In your role as a medical assistant it is important that everything that needs to
be documented in a patient's chart is DOCUMENTED and that it is done in the right format and
tone! Always remember: the patient's medical record is a legal document. And whatever
wasn't documented = never happened. This omission could become detrimental under certain
circumstances and is intended to protect everybody involved.
The SOAP note documentation should briefly express the following:

Date and purpose of the visit

The patients symptoms and complaints

The current physical exam: patient's height, weight, temperature, pulse, blood pressure,
visual acuity, etc.

New lab data and results of studies, reports, assessments

The current formulation and plan for the patient

SOAP Note Writing

SOAP Note Content - Length - And Purpose

The SOAP note is not supposed to be as detailed as a progress report. Complete sentences are
not necessary and abbreviations are appropriate. However, avoid them until you have a handle on
how the abbreviations are usedthey differ for each specialty and are consistent within the
medical office where you work.
SOAP Note Examples

The length of the note will differ for each specialty as well. SOAP notes can be flexible. You
will develop your own style as you try to accommodate office preferences. The note written by a
novice will usually turn out to be a little longer than that of the more advanced staff with more
clinical judgment and experience in proper SOAP note writing format. It is practice that makes
perfect.

An inexperienced writer will often give more thought as to what to write and usually will wind
up putting more of what they have observed to paper than necessary. A short, but precise SOAP
note is often better than an entry that is too verbose. As you experiment and become more
proficient in your routine you will eventually develop your preferred technique to remain short
and accurate.

Medical Assistant SOAP Note Writing >> SOAP Note Review

In your role as a medical assistant you will take vital signs, height, and weight
measurements and enter it into the medical record under the "Objective" SOAP.

Medical Assistant SOAP Note Examples | SOAP Note Parts

See the four parts of a SOAP note and examples how a medical assistant is allowed to
enter them in a patient's record. SOAP note Example 1, SOAP note Example 2...

SOAP Note Parts

SUBJECTIVE The initial portion of the SOAP note format consists of subjective observations. These are
symptoms the patient verbally expresses or as stated by an accompanying relative or 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.
OBJECTIVE 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 diagnostic tests.
ASSESSMENT 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.
PLAN 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, shortterm, 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.

Medical Assistant SOAP Notes

Examples are as a medical assistant would enter the patient's demographics, and
subjective, and objective segment into a patient's record. The assessment and
plan is written by the doctor. The entries are initialed by the medical assistant,
while the provider signs them also.
Abbreviations key:
WT = weight
HT = height
IBW = ideal body weight
BP = blood pressure
Chol = cholesterol
Pt = patient
RTO = Return to office
ROM = range of motion
R/O = rule out
PA= posterior/anterior

NKDA = No known drug allergies

NKA = No known allergies
P = pulse
Temp or T = temperature
BS = blood sugar
UA = urinalysis
VA = vision acuity
O.S. = left eye
O.D. = right eye
O.U. = both eyes

Writing the SOAP Note

Soap Note Example 1:

Patient Name: Robert Kryle DOB: 12/31/1961
Record No. K-6112r809
Date: 09/09/1999
SPt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class
reunion is next year and she would like to begin working toward a weight loss goal that is realistic. NKDA, NKA.
OWT = 210 lbs HT = 60 BW = 115 lbs Chol = 255 BP = 120/75
AObese at 183% IBW, hypercholesterolemia
PLong Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal:
Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and
smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one
week.

- B. Ridman, CCMA
M. Myer, MD

Soap Note Example 2:

Patient Name: Lisa Brown DOB: 2/3/1960

Record No. B-583uw809
Date: 10/19/2001
SPt. here for weekly BP check, no complaints. NKDA, NKA.
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue Atenolol; RTO 6 months

- M.T., CMA
Carlos Monila, MD

Soap Note Example 3:

Patient Name: Lisa Brown DOB: 2/3/1958
Record No. B-583uw809
Date: 04/21/2005
SPt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue Atenolol; RTO 6 months

- Daisy Rodriguez, CCMA

Paula Klein, MD

Soap Note Example 4:

Patient Name: Robert Dreg DOB: 09/17/1967
Record No. D-679dk978
Date: 12/4/2007
SPain in left hip x 3 months; worse when walking or doing exercise. NKDA.
OWt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness.
APossible osteoarthritis; R/O rheumatoid arthritis
Pblood worksed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2
months.

- B. Ridman, CCMA
Brenda D. Fisgers, MD

Soap Note Example 5:

Patient Name: Paul Kessler DOB: 11/03/1961
Record No. K-470pk624
Date: 21/8/2008

SMild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening
at tip of penis, NKA.
ODischarge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is
positive.
ANon-Gonorrheal Urethritis
PDoxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for
10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices.

- R. W., RMA
Ted Ricca, MD
What is a SOAP Note?
http://www.medicalassistant.net/soap_note.htm
Writing a SOAP Note
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What is a SOAP Note?

SOAP notes are written into the patient's medical record during the course of a physical or
medical examination by the physician and other licensed health care providers. This entry serves
as a permanent record of a patient's condition and treatment for future reference. With correct
training and proper supervision a medical assistant is allowed to briefly interview the patient
and enter the patient's reason for the visit under the "Subjective" line of the SOAP note.
Think about it! The health care industry is booming and you want to land a better job but
with a large number of other medical assistants applying for the same jobs and competing with
you, you HAVE to your part to set yourself apart from the rest, or otherwise you may quickly
find yourself left behind.

When is the SOAP Note Written?

The reason for the visit is entered into the "Subjective" (S) of the SOAP note exactly as
the patient stated.

As the medical assistant takes the patient's vital signs, height, and weight measurements it
can be entered into the medical record under the "Objective" area (O) to be reviewed
minutes later by the physician.

The medical assistant may also ask about medications taken, and whether the patient has
any known allergies to environmental substances, food, or medicines.

The patient's response is also listed carefully and accurately under the "O" part of the
SOAP note.

REMEMBER: The medical assistant NEVER writes the "Assessment" (A) or the "Plan" (P)
in a SOAP note, but should be able to understand this vital part of the medical record entry when
reviewing the patient's chart.

SOAP Note Writing Tips:

1. You should start your entry into the medical record right after the last note in the chart so
it will always be in chronological sequence.
2. It is okay to be bold in your presentations, but conservative when charting.
3. Since the patient's medical record is a legal document write fluently and legibly and do
not leave blank lines in between the text. This is to prevent someone else from writing
additional information or comments into your original note. If you made a mistake,
simply cross out the unwanted part of the sentence, whether its just one word or several
sentences, with a single horizontal line. Then write error next to or above the corrected
area and initial it.
4. Never scribble over any part of the note, or use "white-out" to cover a mistake. Those
who read and examine a medical record must be able to see mistakes and know who is
responsible for crossing a word or sentences out.
5. For neatness' sake you may want to start at the top of a page and avoid too much (any)
blank space above your note. You should also provide room for the doctor, to amend and
initial your note at the end.
Soap Note Examples

Last but not least: always sign your notes after your printed name and include your professional
title or credentials. Once again, always leave room on the same page for your notes to be
amended and cosigned by the physician under whose supervision you are working. This is
important for both medico-legal purposes and so others can contact you with questions about
what you have written.

What is a SOAP Note?

http://www.medicalassistant.net/soap_note.htm

Soap Note Example 1:

Patient Name: Robert Kryle DOB: 12/31/1961
Record No. K-6112r809
Date: 09/09/1999
SPt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class
reunion is next year and she would like to begin working toward a weight loss goal that is realistic. NKDA, NKA.
OWT = 210 lbs HT = 60 BW = 115 lbs Chol = 255 BP = 120/75
AObese at 183% IBW, hypercholesterolemia
PLong Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal:
Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and
smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one
week.

- B. Ridman, CCMA
M. Myer, MD

Soap Note Example 2:

Patient Name: Lisa Brown DOB: 2/3/1960
Record No. B-583uw809
Date: 10/19/2001
SPt. here for weekly BP check, no complaints. NKDA, NKA.
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue Atenolol; RTO 6 months

- M.T., CMA
Carlos Monila, MD

Soap Note Example 3:

Patient Name: Lisa Brown DOB: 2/3/1958
Record No. B-583uw809
Date: 04/21/2005

SPt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex
OBP 142/88; Atenolol 50 mg daily
Ahypertension controlled
PContinue Atenolol; RTO 6 months

- Daisy Rodriguez, CCMA

Paula Klein, MD

Soap Note Example 4:

Patient Name: Robert Dreg DOB: 09/17/1967
Record No. D-679dk978
Date: 12/4/2007
SPain in left hip x 3 months; worse when walking or doing exercise. NKDA.
OWt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness.
APossible osteoarthritis; R/O rheumatoid arthritis
Pblood worksed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2
months.

- B. Ridman, CCMA
Brenda D. Fisgers, MD

Soap Note Example 5:

Patient Name: Paul Kessler DOB: 11/03/1961
Record No. K-470pk624
Date: 21/8/2008
SMild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening
at tip of penis, NKA.
ODischarge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is
positive.
ANon-Gonorrheal Urethritis
PDoxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for
10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices.

- R. W., RMA
Ted Ricca, MD