SOAP Notes


Article Author:
William Gossman
Valerie Lew


Article Editor:
Sassan Ghassemzadeh


Editors In Chief:
Donald Kushner
Annabelle Dookie


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/11/2019 11:38:31 PM

Introduction

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.[1][2][3]

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers 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 between 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.[4][5][6]

Function

Structure

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below.

Subjective

This 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 section provides context for the Assessment and Plan.

Chief Complaint (CC)

The 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.

  • Examples: chest pain, decreased appetite, shortness of breath.

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

History of Present Illness (HPI)

The HPI begins with a simple one line opening statement including the patient's age, sex and reason for the visit.

  • Example: 47-year old female presenting with abdominal pain.

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 going on for?
  • 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, 1 being the least, 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: 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: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Review of Systems (ROS)

This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.

  • General: Weight loss, decreased appetite
  • Gastrointestinal: Abdominal pain, hematochezia
  • Musculoskeletal: Toe pain, decreased right shoulder range of motion

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. 

  • Example: Motrin 600 mg orally every 4 to 6 hours for 5 days

Objective

This section documents the objective data from the patient encounter. This includes:

  • 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 diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

  • Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Repeat for additional problems

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:

  • 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 consults
  • Patient education, 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.

Issues of Concern

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order. For instance, rearranging the order to form APSO (Assessment, Plan, Subjective, Objective) provides the information most relevant to ongoing care at the beginning of the note, where it can be found quickly, shortening the time required for the clinician to find a colleague's assessment and plan. One study found that the APSO order was better than the typical SOAP note order in terms of speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Re-ordering into the APSO note is only an effort to streamline communication, not eliminate the vital relationship of S to O to A to P.

A weakness of the SOAP note is the inability to document changes over time. In many clinical situations, evidence changes over time, requiring providers to reconsider diagnoses and treatments. An important gap in the SOAP model is that it does not explicitly integrate time into its cognitive framework. Extensions to the SOAP model to include this gap are acronyms such as SOAPE, with the letter E as an explicit reminder to assess how well the plan has worked.[7][8][9][10]

Clinical Significance

Medical documentation now serves multiple needs and, as a result, medical notes have expanded in both length and breadth compared to fifty years ago. Medical notes have evolved into electronic documentation to accommodate these needs. However, an unintended consequence of electronic documentation is the ability to incorporate large volumes of data easily. These data-filled notes risk burdening a busy clinician if the data are not useful. As importantly, the patient may be harmed if the information is inaccurate. It is essential to make the most clinically relevant data in the medical record easier to find and more immediately available. The advantage of a SOAP note is to organize this information such that it is located in easy to find places. The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow.


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SOAP Notes - Questions

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What part of the SOAP mnemonic does disease severity fall under?



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What part of the SOAP note do the patient's complaints fall under?



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What part of the SOAP note does physical examination fall under?



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Which part of a SOAP note would contain the following statement? "The patient is to do home exercises every other day for the next week."



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A patient is referred for OT evaluation after admission to a psychiatric unit. Chart review, performance measures, and interview are done. Which information will come from the interview portion?



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The OT is documenting after a group. Which of the following is an appropriate for the objective section?



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Select the phrase that belongs in the objective section of a progress note.



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Which of the following statements would be best placed in the subjective section of a SOAP note?



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An OT has observed a stroke patient eating breakfast. Select the statement that is purely observational.



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A patient states that she feels her treatment is going well. Which section of a SOAP note should contain this information?



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Patient's comments should go in which of the following sections?



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A patient is noted to favor the left leg when walking. In which part of the note would this be recorded?



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A 45-year old female present's to your clinic for abdominal pain. She states the pain started 2 days ago, in the middle of her stomach, constant, radiating to her right lower quadrant, worse with movement, better with staying still. She rates the pain 8/10. What part of the SOAP note do the above statements appear?



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A patient reports "my toe hurts." Under which heading of the SOAP note should this be written?



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What are examples of differential diagnoses for a female with right lower quadrant pain with fevers?



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A 65-year old male is seen at your clinic for "not having a bowel movement in 2 days." You decide the patient can go home and take a laxative and follow up in clinic if he still does not have a bowel movement. Which part of the SOAP note should this be documented?



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A 41-year-old female comes to your clinic for weight loss. During the encounter, the physician notices ecchymosis scattered over her arms and legs. The patient does not mention these bruises. Under which section of the SOAP note should the ecchymosis be documented?



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SOAP Notes - References

References

Gogineni H,Aranda JP,Garavalia LS, Designing professional program instruction to align with students' cognitive processing. Currents in pharmacy teaching     [PubMed]
Andrus MR,McDonough SLK,Kelley KW,Stamm PL,McCoy EK,Lisenby KM,Whitley HP,Slater N,Carroll DG,Hester EK,Helmer AM,Jackson CW,Byrd DC, Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE. American journal of pharmaceutical education. 2018 Nov;     [PubMed]
Lisenby KM,Andrus MR,Jackson CW,Stevenson TL,Fan S,Gaillard P,Carroll DG, Ambulatory care preceptors' perceptions on SOAP note writing in advanced pharmacy practice experiences (APPEs). Currents in pharmacy teaching     [PubMed]
Sando KR,Skoy E,Bradley C,Frenzel J,Kirwin J,Urteaga E, Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in pharmacy teaching     [PubMed]
Belden JL,Koopman RJ,Patil SJ,Lowrance NJ,Petroski GF,Smith JB, Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less. Journal of the American Board of Family Medicine : JABFM. 2017 Nov-Dec;     [PubMed]
Santiago LM,Neto I, SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context. Acta medica portuguesa. 2016 Dec 30;     [PubMed]
Lenert LA, Toward Medical Documentation That Enhances Situational Awareness Learning. AMIA ... Annual Symposium proceedings. AMIA Symposium. 2016;     [PubMed]
Rivkin A, Thinking Clinically from the Beginning: Early Introduction of the Pharmacists' Patient Care Process. American journal of pharmaceutical education. 2016 Dec 25;     [PubMed]
Dolan R,Broadbent P, A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving. Annals of medicine and surgery (2012). 2016 Feb;     [PubMed]
Seo JH,Kong HH,Im SJ,Roh H,Kim DK,Bae HO,Oh YR, A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean journal of medical education. 2016 Jun;     [PubMed]

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