SOAP Note

A SOAP note (an acronym for Subjective, Objective, Assessment, and Plan) is a widely used method of documentation for providers of health services. The SOAP format provides a structured framework for organizing patient information, facilitating clear clinical reasoning and communication among healthcare professionals. It is a core component of the problem-oriented medical record (POMR), where a separate SOAP note is written for each of the patient's problems.

The method was developed by Dr. Lawrence Weed in the 1960s to improve the quality and organization of clinical documentation. When a patient's chart is documented using this method, it is often referred to as being "soaped," and the records themselves are sometimes called "soap charts."

The Four Components of a SOAP Note

Each SOAP note consists of four sections, which follow a logical progression from the patient's personal account to the clinician's plan of action.

S: Subjective

This section contains information obtained directly from the patient or their guardian. It is their personal narrative of their condition. The information is "subjective" because it is based on personal feelings, perceptions, and opinions.

The subjective section typically includes:

• Chief Complaint (CC): The main reason for the visit, in the patient's own words (e.g., "I have a sore throat.").
• History of Present Illness (HPI): A detailed account of the chief complaint, including onset, duration, severity, location, quality, context, modifying factors, and associated symptoms.
• Past Medical History (PMH): Previous illnesses, surgeries, and chronic conditions.
• Medications and Allergies.
• Family History (FH) and Social History (SH).
• Review of Systems (ROS): A series of questions about other potential symptoms throughout the body.

O: Objective

This section contains factual, measurable, and observable data obtained through the healthcare provider's own examination and diagnostic tests. This information is "objective" because it is free from the patient's interpretations.

The objective section typically includes:

• Vital Signs: Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation.
• Physical Examination Findings: Observations from inspecting, palpating, percussing, and auscultating the patient.
• Laboratory Results: Blood tests, urine tests, etc.
• Imaging Studies: X-rays, CT scans, ultrasound results.
• Other Diagnostic Data: Results from EKGs, spirometry, etc.

A: Assessment

The assessment is the clinician's synthesis and analysis of the subjective and objective information. It represents the professional's diagnosis or working diagnosis for the patient's problem.

This section may contain:

• A specific diagnosis: For example, "Acute Streptococcal Pharyngitis."
• A list of differential diagnoses: A list of possible diagnoses, usually ranked in order of likelihood.
• An evaluation of progress: For established problems, this section might discuss whether the condition is improving, worsening, or stable.

P: Plan

The plan outlines the immediate steps that will be taken to address the patient's problem. It details the management strategy for the diagnosis identified in the Assessment.

The plan may include:

• Further diagnostic tests: Ordering additional labs or imaging.
• Therapeutic interventions: Prescribing medications, performing a procedure, or recommending physical therapy.
• Patient education: Providing information about the condition and treatment plan.
• Referrals: Arranging for consultation with a specialist.
• Follow-up: Instructions for when the patient should return or what to do if symptoms change.

Example of a SOAP Note

Problem: Sore Throat

• S: Patient is a 25-year-old male who complains of a severe sore throat for the past 2 days. He reports pain on swallowing is an 8/10. He denies cough but notes a mild fever and headache since yesterday.
• O: Vitals: Temp 38.4°C, BP 122/78, HR 90, RR 16. Physical Exam: Pharynx is erythematous with bilateral tonsillar swelling and white exudates. Tender anterior cervical lymphadenopathy noted on palpation.
• A: Acute pharyngitis, likely bacterial (Streptococcal) based on clinical findings (fever, exudates, tender lymphadenopathy).
• P:
  1. Perform Rapid Strep Test in office.
  2. If positive, prescribe Amoxicillin 500 mg twice daily for 10 days.
  3. If negative, send throat culture for confirmation.
  4. Advise ibuprofen for pain and fever management.
  5. Recommend salt-water gargles and increased fluid intake.
  6. Patient to follow up if symptoms do not improve in 48-72 hours or worsen.