What is a SOAP Note?
A SOAP note is a documentation method used by medical practitioners to assess a patient’s condition. It is commonly used by doctors, nurses, pharmacists, therapists, and other healthcare practitioners to gather and share patient information. SOAP notes are designed to improve the quality and continuity of patient care by enhancing communication between practitioners and assisting with the recall of specific details.
There are four main parts of a SOAP note which are designed to help improve evaluations and standardize documentation:
- Subjective - What the patient tells you
- Objective - What you see
- Assessment - What you think is going on
- Plan - What you will do about it
This article covers: 1) how to write a SOAP note; 2) downloadable SOAP note templates; and 3) technology to help you streamline SOAP note reporting.
Click here to download top 3 SOAP note templates.
How to Write a SOAP Note
Writing in a SOAP note format allow healthcare practitioners to conduct a clear and concise documentation of patient information. This method of documentation helps the involved practitioner get a better overview and understanding of the patient’s concerns and needs.
Below are ways you can effectively write a SOAP note:
Subjective - What the Patient Tells you
This section refers to information verbally expressed by the patient. Take note of the patient ’s complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes. It can be written like this:
Subjective: Patient states: “My throat is sore. My body hurts and I have a fever. This has been going on for 4 days already.”
Patient is a 23-year-old female. Prior to this, patient says she had a common cold and whooping cough then progressed to the current symptoms.
Objective - What you see
This section consists of observations made by the clinician. Do a physical observation of the patient’s general appearance and also take account of the vital signs (i.e temperature, blood pressure etc). If special tests were conducted, the results should be indicated in this section. Using the previous example, we can write the objective like this:
Objective: Vital signs represent a temperature of 39°, BP of 130/80. Patient displays rashes, swollen lymph nodes and red throat with white patches.
Assessment - What you think is going on
This section tells the diagnosis or what condition the patient has. The assessment is based on the findings indicated in the subjective and objective section. This section can also include diagnostic tests ordered (i.e x-rays, blood work) and referral to other specialists. Using the same example, the assessment would look like this:
Assessment: This is a 23-year-old female with a history of common cold and whooping cough and reporting for a sore throat, fever, and fatigue. Clinical examination suggests bacterial pharyngitis due to swollen lymph nodes and the presence of white patches on the throat.
- High Fever (caused by pharyngitis)
Plan - What you will do about it
This section addresses the patient’s problem identified in the assessment section. Elaborate on the treatment plan by indicating medication, therapies, and surgeries needed. This section can also include patient education such as lifestyle changes (i.e food restrictions, no extreme sports etc). Additional tests and follow up consultations can also be indicated. With the same example, the plan section can be written like this:
- Acetaminophen - take every 6 hours x 5 days
- Penicillin (500mg) - once a day for 5 days
No labs or consults. Follow up after 5 days if symptoms persist or worsen. Drink plenty of water and intake Vitamin C
iAuditor is the world’s leading digital form application. Healthcare professionals can use iAuditor to digitally gather SOAP notes. Collect photo evidence for a more informative and descriptive patient record. Easily share your findings with other healthcare clinicians and avoid losing track of patient records by securely saving it in the cloud using iAuditor.
To help you get started we have created 3 best SOAP note templates you can download and customize for free.