The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for health care providers. The SOAP note is a way for health care workers to document in a structured and organized way.

The SOAP note helps guide health care workers to use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient, as well as a communication document among health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

SOAP Notes Structure

The four headings of a SOAP note are Subjective, Objective, Assessment, and Plan. Each heading is described below.

Subjective

Subjective information is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient, or someone close to them. In the inpatient setting, interim information is included here. This information provides context for the Assessment and Plan.

Chief Complaint

The chief complaint (CC) or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis, or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

However, a patient may have multiple CCs, and their first complaint may not be the most significant one. Thus, clinicians should encourage patients to state all their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform an effective and efficient diagnosis.

History of Present Illness (HPI)

The history of present illness (HPI) begins with a simple one-line opening statement, including the patient’s age, sex. and reason for the visit.

This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been occurring?
• Characterization: How does the patient describe the CC?
• Alleviating and aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10 with “1” being the least and “10” being the worst, how does the patient rate the CC?

It is important for clinicians to focus on the quality and clarity of their patient’s notes rather than include excessive detail.

History

• Medical history: Determine pertinent current or past medical conditions.
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient’s family.
• Social History: Assess the client’s social history. An acronym that may be used here is HEADSS, which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Home and Current Medications/Allergies

Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented to include the medication name, dose, route, and how often.

Objective

This section documents the objective data from the patient encounter, which includes the following:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.

A common mistake is distinguishing between symptoms and signs. Symptoms are the patient’s subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.

Assessment

This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following:

Problem

List the problem list in order of importance. A problem is often known as a diagnosis.

Differential Diagnosis

This is a list of the different possible diagnoses, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth.

Plan

This section details the need for additional testing and consultation with other clinicians to address the patient’s illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem, include the following:

• State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative.
• Therapy needed (medications).
• Specialist referral(s) or consult(s).
• Patient education and/or counseling.

A comprehensive SOAP note has to take into account all subjective and objective information and accurately assess it to create the patient-specific assessment and plan^[1].