What Are SOAP Notes?

SOAP notes are the most effective way to write progress notes for your patients, enabling you to professionally organize your work in a way that can be understood by healthcare professionals across a variety of disciplines. Not only are they essential for legal compliance, but SOAP notes are also an excellent medical documentation formatting structure that covers four aspects that are integral to the success of patient treatment. 

‍
Using medical software, clinical notes can be made easy, but regardless of your decision on whether to use these systems, it is important to understand the constitution of a SOAP note. In knowing this, you can better capture the current state of your clients’ conditions, and work towards effective treatment that specifically addresses problematic symptoms. Over 80% of healthcare professionals use the SOAP note format due to its universal recognition and versatility, which makes them a great option for you to implement into your practice.

There are four essential components to a SOAP note, including subjective, objective, assessment, and plan. These sections must be included for the progress note to be effective. 

Subjective (S)

• This section refers to information regarding the patient’s experience and feelings and their perception of symptoms. It is entirely based on their view and often contains verbatim quotes as supporting evidence. Their relevant symptoms and complaints should be noted first. 
• The severity, duration, and location of their symptoms should also be recognized, as well as the extent to which they are affecting the patient’s everyday life. 
• Because this is subjective, there should be no personal comments or information that can be deemed as one’s own interpretations. It is subjective according to the patient, not you as the practitioner. 
• Susan is feeling down with low self-worth, as she outlines, “I feel like I am a failure at work. I work very hard, but I have always been overlooked, and my self-confidence plummets. It’s affecting how I am at home, and I’m beginning to feel miserable.”
  

Objective (O)

• This is concerned with measurable and quantifiable data that can support signs of symptoms. This may include laboratory tests, x-rays, examinations, as well as recordings of vital signs including height, weight, sleeping patterns, blood pressure levels, and any other physiological indications.
• You may also comment on information such as the patient’s body language in the session, as well their attentiveness, and perceived nervousness. Be careful that this does not translate as an assumption, as it still needs to be objective in that any healthcare professional would also agree with your professional opinion.  
• Any results relevant to the patient’s condition must be reported, including blood tests and CT scans. 
• Susan has a flat expression and is slumped in her chair. She presents low symptoms and indicates feelings of low self-esteem that are beginning to impair her day-to-day functioning.  
  

‍Assessment (A)

• The assessment section is the evaluation of the patient and their symptoms and is the synthesis of both the subjective and objective information presented. 
• It is based on clinical criteria, which may have references to established models, such as the DSM, as well as professional practitioner opinion. 
• Commentary is encouraged on the progress of the patient in comparison to previous sessions, and whether they demonstrate any improvements towards their objectives or goals.
• It serves as a logical progression point from which the plan is formed, and it illustrates clear medical reasoning behind the planned treatment. 
• This is Susan's second session, and she is working on ways to communicate her feelings to her work while realizing her self-worth. Failure to do so will likely result in increased depressive feelings for Susan. She does not seem to have markedly improved since our previous session, so we will be developing upon her current coping strategies. 
  

‍Plan (P)

• The plan involves the future course of action concerning the patient’s treatment and builds upon what was outlined in the assessment section.
• There should be specific, clear, and achievable goals for the patient to work on between sessions, and the practitioner needs to work with the patient to ensure that these goals are plausible. 
• Future sessions may concern additional behavioral techniques, expanding upon ones that have been learned, or referrals to other healthcare providers such as psychiatrists. In some cases, the patient may need to be prescribed medication. 
• Susan will attend further sessions, and we have conducted a plan to work on her perception of self and ways to problem-solve at work. If symptoms do not improve within the next two weeks, we will discuss additional treatment and reevaluation. This includes group therapy, or further behavioral techniques decided by consultation with her other healthcare providers.

Having good clinical documentation is a central aspect of providing patients with quality healthcare. To produce efficient and high-quality SOAP notes, we have included a list of critical factors that you must keep in mind when writing your progress notes. There are various aspects you must consider, and incorporating these are sure to bring about success within your practice. 

• Professional writing style - Having a professional writing style means writing objectively, without personal comments, assumptions, speculations, or judgments. Naturally, you can interject with professional opinion at times, but maintaining professionalism as a whole makes it easier for other healthcare professionals to review your work. This also includes having clear grammar and spelling, with little to no abbreviations, and treating your patients with respect.
• Quality over quantity - Your notes should be concise, and not exceed two pages in length. You should not repeat information, and all comments should be concise and to the point. This will also make it easy for other practitioners who need to read your notes to gain an understanding of the patient.
• Be timely - You shouldn’t write your notes too early so as not to interrupt the appointment with your patient, but they should not be left too late as you may miss critical information. They should be composed relatively soon after the appointment to ensure you’re representing your patient truthfully and honestly. ‍
• Use a recognized correcting method - If you make a mistake, strike a line, initial the mistake, and move on, even if you use electronic health records. This way, others can view the original content, as well as who made the mistake, which is especially important for legal purposes.

SOAP notes are an incredibly effective way to communicate essential clinical documentation regarding your patient’s health condition in a format that is widely understood by healthcare professionals.

Many healthcare businesses incorporate progress notes into their workflow, and with the correct application, such as Carepatron, this process can be made highly accessible. Carepatron allows you to compile essential clinical documents online in a safe, secure, and confidential way. Your progress notes will be encrypted in compliance with HIPAA guidelines, and embedded progress note templates are provided for your convenience. 

Keeping your clients' goals is of great importance. Progress notes need to be easily understood, and with careful consideration, you can design the best treatment plans for your patients that are guaranteed to drive the success of your medical clinic. 

Further reading:

• Generating SOAP Notes from Doctor-Patient Conversations Using Modular Summarization Techniques
• SOAP format for clinical rounds