Writing A SOAP Note
Problem Heading: Every note should have a heading at the top indicating the problem, either in terms of the patient's complaint or in terms of the diagnosis. Encounters with multiple problems should have each problem written as a separate SOAP format.
Subjective: The first problem in any encounter should begin with the patient's age and sex, followed by the chief complaint. The subjective section should include the history of the present illness, including pertinent positives and negatives. This may be followed by relevant past medical history, family history, social history, and/or current medications.
Objective: The relevant aspects of physical examination should be described in standard format:
1. General appearance
2. HEENT
3. Neck and back
4. Lungs
5. Cardiac
6. Breast exam
7. Abdominal exam
8. Pelvic or genital/rectal exam
9. Extremities
10. Neurological exam
Only the relevant portions of exam should be described; the order should not vary. This should be followed by relevant laboratory or x-ray results from the current or previous encounters.
Assessment: If the diagnosis is definite or likely, it should be clearly stated. If the diagnosis is uncertain, the primary symptom may be stated and the differential diagnosis described, including indications of the likelihood of various possibilities. The assessment is NOT the plan. The common practice of A/P is discouraged at this stage in your learning. You assessment should provider the reader with a clear picture of your thinking and justification for the plan.
Plan: All instructions, medications, pending tests, and other discussions with the patient should be documented clearly. The medication data should include dosage, instructions, number of tablets/amount, and refills. Document the instructions and warnings that you gave the patient as well.
The plan for follow-up, by telephone, writing, or a return encounter, should be indicated, along with instructions on what the patient is to do if the symptoms do not respond as expected. Any referrals should be indicated with the name of the physician the patient is to see, if that is available. The plan should also document patient education.
In some cases, the history and examination for several problems will be closely related, and difficult to separate into independent SOAP notes (e.g., diabetes and obesity, HTN and CAD). In those cases, it may be acceptable to write one subjective and objective section, with related assessments and plans. This should not be the norm, but may occur in occasional situations.
Subjective: The first problem in any encounter should begin with the patient's age and sex, followed by the chief complaint. The subjective section should include the history of the present illness, including pertinent positives and negatives. This may be followed by relevant past medical history, family history, social history, and/or current medications.
Objective: The relevant aspects of physical examination should be described in standard format:
1. General appearance
2. HEENT
3. Neck and back
4. Lungs
5. Cardiac
6. Breast exam
7. Abdominal exam
8. Pelvic or genital/rectal exam
9. Extremities
10. Neurological exam
Only the relevant portions of exam should be described; the order should not vary. This should be followed by relevant laboratory or x-ray results from the current or previous encounters.
Assessment: If the diagnosis is definite or likely, it should be clearly stated. If the diagnosis is uncertain, the primary symptom may be stated and the differential diagnosis described, including indications of the likelihood of various possibilities. The assessment is NOT the plan. The common practice of A/P is discouraged at this stage in your learning. You assessment should provider the reader with a clear picture of your thinking and justification for the plan.
Plan: All instructions, medications, pending tests, and other discussions with the patient should be documented clearly. The medication data should include dosage, instructions, number of tablets/amount, and refills. Document the instructions and warnings that you gave the patient as well.
The plan for follow-up, by telephone, writing, or a return encounter, should be indicated, along with instructions on what the patient is to do if the symptoms do not respond as expected. Any referrals should be indicated with the name of the physician the patient is to see, if that is available. The plan should also document patient education.
In some cases, the history and examination for several problems will be closely related, and difficult to separate into independent SOAP notes (e.g., diabetes and obesity, HTN and CAD). In those cases, it may be acceptable to write one subjective and objective section, with related assessments and plans. This should not be the norm, but may occur in occasional situations.
