The podcast above and article below share different information. Listen and read to both to get the most out of this post!
Today we will be diving into a topic that will not only be important for health professional students, but will also be useful and crucial for the entirety of one’s career as a healthcare professional.
We will be discussing medical documentation, but more specifically, the SOAP note.
Just like most things in medicine, there is “more than one way to skin a cat”. Meaning that there is a myriad of different ways to write a SOAP note, and one preceptor or supervising physician may want it a specific way versus another. The biggest thing to remember is that SOAP notes are malleable and will change from provider to provider and from specialty to specialty.
But first, I want to share an example of both the first SOAP note I wrote in PA school, as well as the final SOAP note I wrote from my first year of PA school. You can download those below:
How to Write a SOAP Note
The purpose of a SOAP note is to record information from a patient encounter. This information can come from the patient themselves, friends, family members, other databases, and other healthcare professionals or studies. The goal of the SOAP note is to accurately ascertain the information that is needed to know about the patient and their disease process so that you can make an accurate diagnosis and provide advice on the most appropriate treatment.
The written record also provides a means of communication between you and your professional colleagues, and can aid as a track record for future healthcare providers who might encounter the same patients. Documentation should be completed in a fashion that allows the reader to “see” what you observed, discussed, and plan to do with the patient.
What Makes Up the SOAP Note?
SOAP is an acronym standing for:
- S: Subjective
- O: Objective
- A: Assessment
- P: Plan
The subjective portion contains information that is obtained from the patient, friends, family members, or other medical records, often using quotes or the patient's own words. This subjective portion of the SOAP note includes an introductory statement summarizing the description of the patient, the main reason why there are presenting at that time (chief complaint), the source of the history and the reliability of such source.
The next portion of the subjective portion is fleshing out the components or the description of the problem. The acronym OLD CARTS has been taught for ages as a guide to asking important questions during the subjective portion of the encounter.
So, how do we ask the corresponding questions related to OLD CARTS? Some easy ways to do this include:
- Onset: When did the problem start?
- Location: Where is the problem located/where is there discomfort?
- Duration: When does the problem occur/how long does the problem last for when it does occur?
- Character: Can you describe the problem?
- Associated symptoms: Do you have any other symptoms that occur? Example for cough, does the patient have any associated shortness of breath, chest pain, body aches, ear pain, sore throat, etc.
- Aggravating Factors: Does anything seem to make the problem worse?
- Relieving Factors: Does anything seem to make the problem better?
- Temporal Factors: Is there any specific time or activity when the problem gets better or worse?
- Severity: How does this problem affect your activities of daily living? Pain scale?
Some final things that can be helpful in the subjective portion of the patient interview can be to ask the patient if they have ever had anything similar to this in the past or what they think might be going on, what the patient expects from the visit, and why the patient chose to come to see you at this time or at this stage.
Lastly, it is important to review the patient’s past medical history, family medical history, risk factors, social factors, and review of systems at this point as well.
The objective portion of the SOAP note includes observations that you have made during the encounter and physical examination. This section also can include laboratory results, radiologic studies, and other diagnostic testing results. Vital signs such as blood pressure, pulse and respiration rates, temperature, pulse oxygenation, weight, and height.
In this portion, you should list out pertinent positives, including listing findings that you found that were abnormal, as well as findings that were normal, but pertinent to the patient’s case.
You should provide a brief description of findings that are normal or within normal limits and also include a list of observations that you did not find as they may be related to the patient’s symptoms. Including these assure other colleagues that you specifically looked for certain abnormalities and did not find them on your examination.
Examples may include that the lung sounds were clear in all fields, without crackles, wheezes, or rhonchi. S1, S2 are presents and normal without splitting, rubs, gallops, or murmurs.
The assessment portion of the SOAP note includes the differential diagnosis for the problem or problems being considered at the current encounter. This includes identifying each of the active problems that you are addressing. For each of these problems, the most likely diagnosis, most likely alternative diagnosis, the evidence supporting the assessment, severity and urgency, and prognosis should all be discussed.
When the problem is known and established, the current status of the condition or symptoms, likelihood of improvements, and complicating factors should all be discussed.
For health maintenance visits, one can include a patient’s risk factors, lifestyle and safety issues in this section as well.
For each numbered assessment as above, in the plan portion, you should provide a likely or suspected diagnosis. Justification for the proposed diagnosis should be completed in the assessment portion. In the plan, you should discuss therapy or treatment such as medications, tests, and recommendations.
Patient education and instructions, advice, education, referrals, follow up, and what to do if symptoms worsen should all be included in the plan portion of the SOAP note as well.
Lastly, as many providers will attest to, frequently there is great overlap between the assessment and plan sections and routinely the SOAP note becomes the SOA/P note. As mentioned previously, there is more than one way to skin a cat, and combining the assessment and plan is perfectly acceptable in some instances, and is what I choose to do in my clinical practice today.
SOAP Note Examples
Something that I always liked to see when I was a physician assistant student were examples of SOAP notes. During my time in PA school, we had to write SOAP notes intermittently on either patient’s that we encountered during rotations, or on your problem-based learning cases.
Again, as mentioned previously in this article, there are many ways to write SOAP notes. From specialty to specialty, and from provider to provider this will vary. These should serve as only an example. As you gain more experience and venture through clinical practice, you will find what works best for you.
- Introduction to Writing a SOAP Notes. SIU PA program. 2016.
- Physical Examination Course. SIU PA Program. 2016.