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This SOAP Note template is a documentation format used by physicians and other health care professionals to assess patient conditions. Use this template for creating concise patient documentation to develop accurate solutions. Follow the points below to utilize this template:
A Subjective, Objective, Assessment, Plan (SOAP) note is a documentation method used by medical practitioners—such as doctors, nurses, pharmacists, and other healthcare practitioners—to assess a patient’s condition. SOAP notes are designed to improve the quality and continuity of patient care by enhancing communication between practitioners and assisting with recall of specific details.
Writing in a SOAP note format allows healthcare practitioners from various fields (e.g., occupational therapy) to conduct clear and concise documentation of patient information. This method of documentation helps the involved practitioner get a better overview and understanding of the patient’s concerns and needs.
Below are SOAP note examples and walkthroughs of how you can effectively write a SOAP note following the SOAP note format depending on your needs:
What the Patient Tells you
This section refers to information verbally expressed by the patient. Take note of the patient ’s complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes.
Subjective: Patient states: “My throat is sore. My body hurts and I have a fever. This has been going on for 4 days already.”
Patient is a 23-year-old female. Prior to this, patient says she had a common cold and whooping cough then progressed to the current symptoms.
What You See
This section consists of observations made by the clinician. Do a physical observation of the patient’s general appearance and also take account of the vital signs (i.e temperature, blood pressure etc). If special tests were conducted, the results should be indicated in this section. Using the previous example, we can write the objective like this:
Objective: Vital signs represent a temperature of 39°, BP of 130/80. Patient displays rashes, swollen lymph nodes and red throat with white patches.
What You Think is Going on
This section tells the diagnosis or what condition the patient has. The assessment is based on the findings indicated in the subjective and objective section. This section can also include diagnostic tests ordered (i.e x-rays, blood work) and referral to other specialists. Using the same example, the assessment would look like this:
Assessment: This is a 23-year-old female with a history of common cold and whooping cough and reporting for a sore throat, fever, and fatigue. Clinical examination suggests bacterial pharyngitis due to swollen lymph nodes and the presence of white patches on the throat.
What You Will Do About It
This section addresses the patient’s problem identified in the assessment section. Elaborate on the treatment plan by indicating medication, therapies, and surgeries needed. This section can also include patient education such as lifestyle changes (i.e food restrictions, no extreme sports etc). Additional tests and follow up consultations can also be indicated. With the same example, the plan section can be written like this:
