The Complete Guide to SOAP Notes
Master the Subjective, Objective, Assessment, Plan format with our comprehensive guide. Includes real examples, templates, and best practices for efficient clinical documentation.
What is a SOAP Note?
A SOAP note is a standardized method for documenting patient encounters in healthcare. The acronym stands for Subjective, Objective, Assessment, and Plan—four sections that organize clinical information in a logical, consistent format.
Developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record (POMR), SOAP notes have become the gold standard for clinical documentation across virtually all healthcare settings.
Why SOAP Notes Matter
- Continuity of care: Other providers can quickly understand patient history and current status
- Legal protection: Thorough documentation supports medical decision-making in malpractice cases
- Billing compliance: Proper documentation supports coding and reimbursement
- Quality improvement: Standardized notes enable outcomes tracking and research
SOAP Note Format: Section by Section
Each section of a SOAP note serves a specific purpose. Understanding what belongs in each section is key to effective documentation.
Subjective
Information reported by the patient or caregiver
What to Include
- Chief complaint (CC)
- History of present illness (HPI)
- Review of systems (ROS)
- Past medical/surgical history
- Medications and allergies
- Social and family history
Pro Tips
- •Quote the patient directly for chief complaint
- •Include pertinent negatives
- •Document timing, quality, severity of symptoms
- •Note what makes symptoms better or worse
Example
Objective
Measurable, observable clinical findings
What to Include
- Vital signs
- Physical examination findings
- Laboratory results
- Imaging findings
- Other diagnostic data
Pro Tips
- •Be specific with measurements
- •Document pertinent normal findings
- •Use standardized terminology
- •Include all relevant exam findings
Example
Assessment
Clinical interpretation and diagnosis
What to Include
- Primary diagnosis with ICD code
- Differential diagnoses
- Clinical reasoning
- Disease severity/staging
- Prognosis
Pro Tips
- •List diagnoses in order of clinical priority
- •Include ICD-10 codes when applicable
- •Document your clinical reasoning
- •Address all active problems
Example
Plan
Treatment plan and next steps
What to Include
- Diagnostic tests ordered
- Medications prescribed
- Referrals made
- Patient education provided
- Follow-up instructions
Pro Tips
- •Be specific with medication dosing
- •Include contingency plans
- •Document patient education
- •Set clear follow-up expectations
Example
Complete SOAP Note Example
Here's a complete SOAP note example for a primary care visit, demonstrating how all four sections work together.
Visit Type: Follow-up
Specialty: Primary Care
SSubjective
CC: "My knee has been hurting for about 2 weeks."
HPI: 45-year-old male presents with right knee pain x2 weeks. Pain started gradually without specific injury. Describes as aching quality, 6/10 severity at worst, located along medial aspect. Worse with stairs, prolonged sitting, and pivoting. Improved with rest and OTC ibuprofen. Denies swelling, locking, catching, or knee giving way. No history of knee trauma or surgery.
ROS: Negative for fever, weight change, other joint pain, morning stiffness, weakness, numbness.
PMH: Hypertension (dx 2019, well-controlled), hyperlipidemia.
PSH: Appendectomy 2010.
Allergies: NKDA.
Medications: Lisinopril 10mg daily, atorvastatin 20mg daily, ibuprofen 400mg PRN.
Social: Works as accountant (desk job), no tobacco, occasional alcohol, walks 2 miles 3x/week.
OObjective
Vitals: BP 128/82, HR 72, Temp 98.4°F, SpO2 99% RA, BMI 27.
General: Alert, oriented, well-appearing, no acute distress.
MSK - Right Knee Exam:
- Inspection: No erythema, ecchymosis, or visible swelling. Normal alignment.
- Palpation: Tenderness to palpation along medial joint line. No warmth. No effusion.
- ROM: Flexion 0-120° (limited by pain at end range), extension full to 0°.
- Special tests: McMurray positive for pain with external rotation, Lachman negative, anterior/posterior drawer negative, negative varus/valgus stress testing.
- Strength: 5/5 quadriceps and hamstrings bilaterally.
- Neurovascular: Intact sensation, 2+ DP/PT pulses.
Gait: Mildly antalgic, favoring right lower extremity.
Left knee: Normal exam for comparison.
AAssessment
1. Right knee pain - likely medial meniscus tear (M23.22)
Clinical presentation consistent with degenerative meniscal pathology: insidious onset, mechanical symptoms, positive McMurray test, isolated medial joint line tenderness in a 45-year-old male. No ligamentous instability on exam.
Differential diagnosis: Knee osteoarthritis, medial collateral ligament sprain, pes anserine bursitis, early inflammatory arthritis.
2. Hypertension - stable (I10)
Well-controlled on current regimen. BP at goal today.
3. Hyperlipidemia - stable (E78.5)
On statin therapy. Due for lipid panel at next visit.
PPlan
1. Right knee pain:
- MRI right knee without contrast ordered to evaluate meniscal integrity
- Continue ibuprofen 400mg TID with food, max 2 weeks (discussed GI risks)
- Physical therapy referral: quadriceps strengthening, ROM exercises, 2x/week x6 weeks
- Activity modification: avoid deep squatting, stairs when possible
- Ice 20 minutes TID for symptom relief
- If no improvement in 4-6 weeks with conservative management, will consider orthopedic surgery referral
2. Hypertension:
- Continue lisinopril 10mg daily
- Recheck BP at follow-up visit
3. Hyperlipidemia:
- Continue atorvastatin 20mg daily
- Order fasting lipid panel for next visit
Patient Education: Discussed likely meniscal pathology, imaging rationale, and conservative management approach. Reviewed red flag symptoms (locking, significant swelling, instability). Patient verbalized understanding and agreement with plan.
Follow-up: 4 weeks, sooner if worsening symptoms or MRI results warrant earlier discussion.
Common SOAP Note Mistakes to Avoid
Even experienced clinicians make documentation errors. Here are the most common mistakes and how to fix them.
Mixing subjective and objective
Mistake:
Writing "patient appears to be in pain" in the Objective section
Better:
Pain is subjective. Document observable signs: "grimacing with movement, guarding right knee"
Vague documentation
Mistake:
"Knee exam normal"
Better:
"Right knee: no effusion, full ROM, negative McMurray/Lachman, stable varus/valgus"
Assessment without reasoning
Mistake:
"Knee pain"
Better:
"Right knee pain - likely medial meniscus tear based on positive McMurray, medial joint line tenderness, and mechanical symptoms"
Incomplete plan
Mistake:
"Start PT"
Better:
"Physical therapy 2x/week x6 weeks for quadriceps strengthening and ROM exercises. Re-evaluate in 4 weeks."
Missing pertinent negatives
Mistake:
Only documenting positive findings
Better:
Include relevant negatives: "denies locking, giving way, no trauma history"
SOAP Notes by Specialty
While the SOAP format is universal, different specialties emphasize different elements. Here's how to adapt your notes.
Primary Care
Focus: Comprehensive health maintenance, chronic disease management
Include preventive care gaps, medication reconciliation, health maintenance items in Plan
Physical Therapy
Focus: Functional status, ROM, strength measurements
Objective should include goniometer readings, manual muscle testing grades, functional outcome measures
Mental Health
Focus: Mental status exam, risk assessment, therapy progress
Objective includes MSE findings; may prefer DAP format; include safety planning in high-risk cases
Emergency Medicine
Focus: Acute stabilization, disposition planning
Time-stamp critical interventions, document medical decision-making for billing, include disposition rationale
Surgery
Focus: Procedural details, wound assessment, post-op status
Include procedure notes as separate documentation; SOAP for follow-up visits should reference surgical details
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Frequently Asked Questions
What does SOAP stand for in medical notes?
SOAP stands for Subjective, Objective, Assessment, and Plan. It is a standardized documentation format used by healthcare providers to organize clinical information in a logical, consistent manner. The format was developed in the 1960s by Dr. Lawrence Weed as part of the problem-oriented medical record.
Who uses SOAP notes?
SOAP notes are used by physicians, nurses, nurse practitioners, physician assistants, physical therapists, occupational therapists, mental health counselors, chiropractors, and virtually all healthcare professionals who document patient encounters. The format is universal across most healthcare settings.
How long should a SOAP note be?
SOAP note length varies by specialty, visit type, and complexity. A typical primary care follow-up might be 200-400 words, while a complex new patient evaluation could be 800+ words. The key is including all clinically relevant information concisely. Quality matters more than length—focus on documenting what supports your clinical decision-making.
What is the difference between SOAP and DAP notes?
SOAP notes have four sections (Subjective, Objective, Assessment, Plan) while DAP notes have three (Data, Assessment, Plan). DAP combines subjective and objective information into a single "Data" section, making it popular in mental health settings where the distinction between subjective reports and objective observations is less relevant.
Can AI write SOAP notes?
Yes, AI medical scribes like PatientNotes can automatically generate SOAP notes from patient conversations. The AI listens to the encounter in real-time, extracts relevant clinical information, and formats it into proper SOAP structure. Providers review, edit if needed, and approve the note—saving 2+ hours daily on documentation.
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