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Soap Notes

SOAP notes are a standardized format used in medical offices to document patient evaluations. The four parts are: 1) SUBJECTIVE - Patient's description of symptoms and health issues. 2) OBJECTIVE - Medical observations like physical exam results and test measurements. 3) ASSESSMENT - The medical provider's opinion on the patient's condition and possible diagnoses. 4) PLAN - Actions to be taken like ordering tests, prescribing medications, making referrals, and providing follow-up instructions.

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300 views1 page

Soap Notes

SOAP notes are a standardized format used in medical offices to document patient evaluations. The four parts are: 1) SUBJECTIVE - Patient's description of symptoms and health issues. 2) OBJECTIVE - Medical observations like physical exam results and test measurements. 3) ASSESSMENT - The medical provider's opinion on the patient's condition and possible diagnoses. 4) PLAN - Actions to be taken like ordering tests, prescribing medications, making referrals, and providing follow-up instructions.

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jhhjjh
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SOAP Notes

SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN. Medical documentation of patient
complaint(s) and treatment must be consistent, concise and comprehensive. Many medical offices use the
SOAP note format to standardize medical evaluation entries made in clinical records. The four parts of a SOAP
note are outlined below.

1. SUBJECTIVE – The initial portion of the SOAP note format consists of subjective comments. These are
symptoms verbally given to medical personnel by the patient or by a significant other (family or friend). These
subjective remarks include the patient’s descriptions of pain or discomfort, the presence or absence of other
symptoms, and a multitude of other descriptions of dysfunction, discomfort or illness.

2. OBJECTIVE – The next part of the format is the objective observation. These objective observations
include signs that medical personnel actually see, hear, touch, feel, or smell. Included in objective observations
are results of the physical exam and measurements such as temperature, pulse, respiration, skin color, swelling
and the results of tests.

3. ASSESSMENT – Assessment follows the objective observations. Assessment is the medical personnel’s
opinion 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 diagnostic possibilities.

4. PLAN – The last part of the SOAP note is the plan. The plan may include things to be done for the patient:
laboratory and/or radiological tests to be ordered, 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 and
follow-up directions for the patient.

The SOAP note is a brief report in the patient’s chart, done at the time of the appointment when the patient is
seen. It is different from the comprehensive note the provider writes in the hospital or at the time of first visit.
The instructions below should give you a general idea of what information to include and where. Many of the
particulars of your notes will be different for each medical specialty, so be sure to get feedback about your notes
and adjust your style accordingly.

The SOAP note should briefly express the following:


--Date and purpose of the visit, the patient’s symptoms and complaints.
--The current physical exam. Include the patient’s height, weight, temperature, pulse, blood pressure, visual
acuity, etc. Include lab data and results of studies, reports (if any).
--The current assessment(s) and plan(s) for the patient.

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