The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD. It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way. Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various members of healthcare professions.
Components
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Subjective component
Chief Complaint (CC)
The patient's chief complaint, or CC, is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization. It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded.
- Onset
- "When did the CC begin?"
- L
- "Where is the CC located?"
- Duration
- "How long has the CC been going for?"
- CHaracter
- "Can you describe the CC you're experiencing?"
- Alleviating/Aggravating factors
- "What makes the CC better and worse?"
- Radiation
- "Does the CC move or stay in one spot?"
- Temporal pattern
- "Is there a particular time of day when the CC is better or worse?"
- Severity
- "On a scale of 1 to 10 (10 being the worst pain you've experienced), how would you rate the CC?"
Variants on this mnemonic include OPQRST, SOCRATES, and LOCQSMAT (outlined here):
- L
- Onset (when injury started and mechanism of injury—if applicable)
- Chronology (better or worse since onset, episodic, variable, constant, etc.)
- Quality (sharp, dull, etc.)
- Severity (usually a pain rating)
- Modifying factors (what aggravates/reduces the symptoms—activities, postures, drugs, etc.)
- Additional symptoms (un/related or significant symptoms to the chief complaint)
- Treatment (has the patient seen another provider for this symptom?)
Subsequent visits for the same problem briefly summarize the HPI, including pertinent testing and results, referrals, treatments, outcomes and follow-ups.
History
Pertinent medical history, surgical history (with year and surgeon if possible), family history, and social history is recorded. Vital signs and measurements, such as weight.
- Findings from physical examinations, including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities. The following areas should be included:
- Physical presentation
- Characterization of discomfort or pain
- Psychological status The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy.
A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
Often the Assessment and Plan sections are grouped together.
An example
A very rough example follows for a patient being reviewed following an appendectomy. This example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in the subjective and objective sections.
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|||Surgery Service, Dr. Jones
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| S: ||No further Chest Pain or Shortness of Breath. "Feeling better today." Patient reports headache.
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| O: ||Afebrile, P 84, R 16, BP 130/82. No acute distress.
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| ||Neck no JVD, Lungs clear
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| ||Cor RRR
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| ||Abd Bowel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.
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| ||Ext without edema
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| A:||Patient is a 37-year-old man on post-operative day 2 for laparoscopic appendectomy. Recovering well.
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| P:||Advance diet. Continue to monitor labs. Follow-up with Cardiology within three days of discharge for stress testing as an out-patient. Prepare for discharge home tomorrow morning.
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The plan itself includes various components:
- Diagnostic component: continue to monitor labs
- Therapeutic component: advance diet
- Referrals: follow up with Cardiology within three days of discharge for stress testing as an out-patient.
- Patient education component: that is progressing well
- Disposition component: discharge to home in the morning