How to Write SOAP Notes: A Step-By-Step Guide

This article will discuss SOAP notes and offer an example of how to write them effectively. Click here to learn the step-by-step guide!

Last Updated on December 29, 2023 by Ossian Muscad

SOAP notes, an acronym for Subjective, Objective, Assessment, and Plan, are a systematic and standardized method for documenting a patient’s progress, interventions, and treatment plans. They play a pivotal role in healthcare, ensuring seamless communication among healthcare professionals, continuity of care, and legal protection. An example of effective documentation is a SOAP note, it is not merely a bureaucratic requirement but a critical component that can significantly impact the quality of care delivered. It tracks a patient’s progress, supports the medical decision-making process, and contributes to formulating an effective treatment plan.

This article aims to provide a comprehensive guide on how to write effective SOAP notes. We will walk you through each step with illustrative examples to empower you with the skills necessary to excel in this crucial aspect of patient care. By mastering SOAP notes, you can enhance the quality of your documentation, improve patient outcomes, and elevate your professional practice.


Understanding SOAP Notes

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. Each letter represents a distinct, crucial component of a complete SOAP note. It is a structured method for documenting any patient’s condition and treatment in healthcare. With its systematic approach, SOAP notes ensure that all essential information is captured while providing a framework for organizing these details concisely and logically.

SOAP notes are widely used in healthcare to ensure comprehensive and organized documentation of a patient’s condition and treatment, facilitating effective communication among healthcare providers. Let’s delve deeper into the four components of SOAP notes. Understanding these elements is fundamental to producing clear, consistent, useful progress notes that capture a patient’s journey.

  1. Subjective: This component describes the patient’s current condition in their own words. It includes the patient’s symptoms, concerns, and feelings about their health.
  2. Objective: Here, the healthcare professional documents objective, observable, and measurable findings from the current visit, such as vital signs, lab results, and physical examination findings.
  3. Assessment: This is the healthcare professional’s interpretation of the patient’s condition. It typically includes diagnosis, differentials, and a review of the patient’s response to any current treatments.
  4. Plan: This final component outlines the next steps for managing the patient’s condition. It includes ordered tests, treatment modifications, patient education, and potential follow-up issues.


Step-by-Step Guide to Writing SOAP Notes

Writing a comprehensive and effective SOAP note requires a systematic approach that ensures all essential elements are captured. Every step matters, and overlooking or omitting any information can result in incomplete or inaccurate documentation. Let’s look at each step of writing SOAP notes with an illustrative example.

Subjective Section

The Subjective section of the SOAP note is the starting point and often sets the tone for the rest of the note. It captures the patient’s perspective about their health condition and how they’re feeling. This is where the healthcare provider gathers subjective information that’s relevant to the patient’s condition, which typically includes:

  1. Gathering Patient Information: This includes demographic data, the reason for the visit, and any personal or family medical history relevant to the current condition.
  2. Asking Relevant Questions: It’s essential to ask patients specific questions regarding their symptoms or concerns to understand their health status better.
  3. Recording Patient History: The provider should take note of the patient’s past medical history, including any previous illnesses, surgeries, or treatments.
  4. Documenting Patient Symptoms: The patient’s symptoms as described by them should be accurately recorded. This includes the nature, duration, intensity, and frequency of the symptoms.

Objective Section

The Objective section of a SOAP note is the next critical step, providing a data-driven and unbiased account of the patient’s current health status. The healthcare professional documents any measurable, observable, and factual information about the patient’s condition. This section differentiates itself from the Subjective section by focusing on complex data obtained during the patient’s visit. Key aspects to include in the Objective section are:

  1. Conducting Physical Examinations: This involves a thorough physical examination of the patient to identify any visible signs associated with their symptoms. This could include skin color, the presence of rashes, swelling, and even how the patient is breathing.
  2. Obtaining Vital Signs: The healthcare professional records vital signs such as temperature, blood pressure, pulse rate, and respiratory rate. These indicators provide immediate information about the patient’s physiological status.
  3. Utilizing Medical Tests and Imaging: If applicable, the results of any medical tests or imaging studies should be documented. This includes blood tests, radiology reports, or other diagnostic procedure results.
  4. Providing Objective and Measurable Data: Any other relevant and measurable data should be included. This could be the patient’s weight, height, or any other objective information that gives further insight into the patient’s health.

Assessment Section

The Assessment section is the third crucial part of a SOAP note, where the healthcare provider interprets the gathered information, identifies potential diagnoses or issues, and organizes them in order of importance. This section bridges the subjective and objective findings with the healthcare provider’s clinical expertise. Critical steps in writing the Assessment section include:

  1. Analyzing the Gathered Information: The healthcare provider reviews the subjective and objective data collected, searching for patterns or markers that could lead to a potential diagnosis.
  2. Identifying Diagnoses or Issues: The provider identifies possible diagnoses or health issues based on the analyzed information.
  3. Using Standardized Language and Codes: To ensure consistency and clarity, the provider uses standardized medical terminology and diagnostic codes where applicable.
  4. Establishing Prioritization of Health Concerns: The provider determines the urgency of each identified diagnosis or issue, ranking them in order of importance to the patient’s wellbeing.

Plan Section

The Plan section is the final, yet vital, component of a SOAP note, where the healthcare provider outlines the course of action for managing the patient’s condition. This section directly stems from the assessment and details the steps to aid the patient’s recovery. It encapsulates the provider’s approach towards the patient’s treatment and care, including:

  1. Developing Treatment Plans: Based on the assessment, the healthcare provider devises a comprehensive treatment plan tailored to the patient’s needs and condition.
  2. Prescribing Medications: Medications necessary for the patient’s recovery are prescribed, considering dosage, frequency, and duration of use.
  3. Recommending Therapies or Interventions: The provider may recommend specific therapies or interventions that could benefit the patient’s health. This could include physical therapy, cognitive-behavioral therapy, or other suitable interventions.
  4. Setting Follow-up Appointments: The provider schedules follow-up dates for re-evaluation, monitoring the patient’s progress, and adjusting the treatment plan as necessary.


Best Practices for Writing SOAP Notes

Effective SOAP note documentation requires adherence to several best practices. These practices ensure clarity, accuracy, and compliance with medical regulations. Let’s delve into key strategies that can enhance SOAP note writing.

Maintaining Clarity and Conciseness

Clarity and brevity are essential in SOAP note writing. Documentation should be straightforward, devoid of ambiguity, and brief, focusing only on relevant information. Unnecessary verbosity or complex jargon can create confusion, potentially leading to misunderstanding or misinterpreting the patient’s condition.

Using Standardized Terminology

Utilizing standardized medical terminology and diagnostic codes ensures consistency in documentation, irrespective of who is reading or writing the notes. Standardization enables clear communication among healthcare professionals and supports accurate record-keeping, insurance claims, and statistical reporting.

Adhering to HIPAA Guidelines

Compliance with the Health Insurance Portability and Accountability Act (HIPAA) guidelines is imperative in SOAP note writing. These guidelines ensure patient confidentiality and privacy. Personal identifying information should only be used when necessary, and all documentation should be securely stored and accessible only to authorized individuals.

Regularly Updating and Reviewing Notes

Regular updates and reviews of SOAP notes are crucial in providing consistent, high-quality patient care. Changes in the patient’s condition, new test results, or modifications in the treatment plan should be promptly documented. Regular reviews allow for identifying trends, progress, or the effectiveness of interventions, enabling necessary adjustments to the patient’s treatment.

Consider a 42-year-old male patient who visits his primary care physician complaining of intermittent chest pains that worsen with activity for the past two weeks. Here’s how a SOAP note would be written for this scenario:

Subjective Section

The patient reports experiencing intermittent chest pain, characterized as sharp, located in the central and left chest area, that worsens with physical activity and is slightly relieved by rest. He also indicates shortness of breath during these episodes. No associated symptoms like nausea, vomiting, or palpitations were reported. The patient has a history of Type 2 diabetes and smoking. There’s no known family history of heart disease.

Objective Section

On examination, the patient appears anxious and is moderately overweight. Vital signs: BP 140/90 mmHg, pulse 90 bpm, respirations 20 per minute, and temperature 98.6°F. Heart sounds are normal with no murmurs. A 12-lead ECG shows ST-segment depression, suggestive of potential cardiac ischemia.

Assessment Section

Considering the patient’s symptoms, history, and objective findings—particularly the ECG changes—there is a high suspicion of Angina Pectoris. The intermittent chest pain induced by physical activity and partially relieved with rest aligns with typical angina symptoms. His risk factors include Type 2 Diabetes and smoking.

Plan Section

The plan is to initiate medical management and lifestyle modification advice in response to the assessment. Medical management includes prescribing sublingual Nitroglycerin for immediate symptom relief and starting long-term anti-anginal therapy with beta-blockers and aspirin. The patient is also advised to quit smoking, engage in moderate physical activity like walking, and adopt a balanced, low-sodium diet. A follow-up appointment is scheduled in two weeks to reassess the patient’s condition and the effectiveness of the treatment plan.

In this SOAP notes example, each section is documented with the necessary details. It succinctly communicates the patient’s symptoms, the provider’s observations and interpretation, and the subsequent action plan. This effective communication can assist in promoting efficient care coordination and enhancing patient outcomes.


Common Mistakes to Avoid

When writing SOAP notes, healthcare providers must avoid certain pitfalls that could compromise the documentation’s quality, accuracy, and comprehensiveness. Avoiding these common mistakes can enhance patient care, facilitate efficient communication among healthcare professionals, and ensure medical regulations and standards compliance.

Incomplete or Inaccurate Information

Incomplete or inaccurate documentation can create confusion, misinterpretation, and inaccuracies in the patient’s health records. Providers should record all pertinent details from the patient’s subjective complaints, objective findings, assessment, and treatment plan. Accuracy in these details is crucial as they directly influence the patient’s care and treatment progress.

Lack of Standardization

Failing to use standardized medical terminology and diagnostic codes can lead to inconsistency, ambiguity, and misunderstandings in SOAP notes. Standardization eradicates these issues, ensuring clear, effective communication among healthcare professionals and supporting accurate record-keeping, insurance claims, and statistical reporting.

Failing to Include Patient Input

SOAP notes should reflect the provider’s observations and incorporate the patient’s input. Patients’ subjective experiences, feelings, and thoughts about their conditions and treatments are crucial in formulating a comprehensive and effective care plan. Neglecting to include this can lead to missed diagnostic cues and patient dissatisfaction.

Neglecting Legal and Ethical Considerations

SOAP notes are legal documents subject to scrutiny in a court of law. Providers should ensure their notes adhere to HIPAA guidelines, maintain patient confidentiality, and are securely stored. The care plan should also consider ethical considerations such as informed consent, respecting patient autonomy, and ensuring non-maleficence.


Tools and Templates for Writing SOAP Notes

Various tools and templates are available to assist healthcare professionals in writing clear, comprehensive, and consistent SOAP notes. These platforms are designed to streamline documentation, improve communication among care providers, and ultimately enhance patient care. Here are three major categories of these tools:

Electronic Health Record (EHR) Systems

EHR systems are digital versions of patient charts and are becoming increasingly prevalent in healthcare settings. These systems allow for the seamless recording and updating of SOAP notes and often include features for flagging anomalies, tracking changes over time, and sharing information with other healthcare providers. This facilitates real-time, coordinated patient care, reduces the likelihood of errors, and aids in maintaining comprehensive and organized patient records.

Printable SOAP Note Templates

Printable SOAP Note templates serve as a structured guide for providers in documenting patient encounters. They outline the key components of SOAP notes—Subjective, Objective, Assessment, and Plan—and provide spaces for detailed information input. These templates can be particularly beneficial for beginners or less experienced providers in ensuring no significant details are overlooked.

Customizable SOAP Note Software

Customizable SOAP Note software provides the most flexibility and specificity in creating SOAP notes. Providers can tailor these digital platforms to suit their needs and preferences, including specific fields, prompts, and drop-down menus. This customization can streamline the documentation process, promote consistency across notes, and enhance patient care’s overall efficiency and quality.


Frequently Asked Questions (FAQs)

Q1: What is the importance of SOAP notes in telemedicine?

Telemedicine has revolutionized the healthcare system, enabling remote patient care. SOAP notes play a crucial role in this domain, providing a structured format for accurately documenting virtual consultations. They help ensure patient records’ consistency, accuracy, and comprehensiveness, facilitating effective remote communication and care.

Q2: Can SOAP notes be used across different healthcare disciplines?

Yes, SOAP notes are versatile and can be utilized across various healthcare disciplines, including nursing, physiotherapy, psychology, and more. Their standardized format allows seamless communication and understanding among different health professionals, ensuring coordinated care for the patient.

Q3: How can SOAP notes contribute to improved patient outcomes?

SOAP notes contribute to improved patient outcomes by providing a structured and comprehensive record of a patient’s health journey. They enable healthcare providers to track and evaluate treatment plans, observe progress, and make necessary adjustments. This ongoing assessment and individualized care approach can result in more effective treatments and better health outcomes.


Streamline SOAP Note Template Creation and Implementation with DATAMYTE

DATAMYTE is a quality management platform with low-code capabilities. Our Digital Clipboard, in particular, is a low-code workflow automation software that features a workflow, checklist, and smart form builder. This tool lets you create standardized, customizable SOAP notes, making the process more efficient and consistent.

DATAMYTE also lets you conduct layered process audits, a high-frequency evaluation of critical process steps, focusing on areas with the highest failure risk or non-compliance. Conducting LPA with DATAMYTE lets you effectively identify and correct potential defects before they become major quality issues.

With DATAMYTE, you have an all-in-one solution for streamlining SOAP note template creation and implementation, enhancing communication and coordination among healthcare providers, and ultimately improving patient care. Book a demo now to learn more.



In conclusion, SOAP notes are fundamental to delivering quality healthcare, providing a structured, comprehensive, and consistent method for documenting patient encounters. The importance of these records cannot be overstated—they bridge communication gaps among healthcare professionals, support the ongoing assessment and tailoring of care plans, and ultimately contribute to improved patient outcomes.

However, their value is realized only when consistently and accurately completed. Thus, Healthcare professionals are encouraged to prioritize their documentation practices, incorporating objective and subjective data and adhering to the necessary legal and ethical considerations. By doing so, they are not only safeguarding themselves legally but are also placing themselves in a stronger position to enhance patient care.



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