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The Four Parts of a SOAP Note
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S - O - A - P
1. SUBJECTIVE
— The initial portion of the SOAP
note format consists of subjective observations.
These are symptoms the patient verbally expresses or
as stated by a significant other. These subjective
observations include the patient's descriptions of
pain or discomfort, the presence of nausea or
dizziness, when the problem
first started, and a multitude of other
descriptions of dysfunction, discomfort, or illness
the patient describes.
2. OBJECTIVE
— The next part of the format is
the objective observation. These objective
observations include symptoms that can actually be
measured, seen, heard, touched, felt, or smelled.
Included in objective observations are vital signs
such as temperature, pulse, respiration, skin color,
swelling and the results of diagnostic
tests.
3. ASSESSMENT
— Assessment follows the
objective observations. Assessment is the
diagnosis of the patient's condition. In some cases
the diagnosis may be clear, such as a contusion.
However, an assessment may not be clear and could
include several diagnosis
possibilities.
4. PLAN — The
last part of the
SOAP note is the health care provider's plan. The
plan may include laboratory and/or radiological tests
ordered for the patient, medications ordered,
treatments performed (e.g., minor surgery procedure),
patient referrals (sending patient to a specialist),
patient disposition (e.g., home care, bed rest,
short-term, long-term disability, days excused from
work, admission to hospital), patient directions (e.g.
elevate foot, RTO 1 week), and follow-up
directions for the patient.
Medical Assistant SOAP NotesExamples are as a medical assistant would enter the patient's demographics, and subjective, and objective segment into a patient's record. The assessment and plan is written by the doctor. The entries are initialed by the medical assistant, while the provider signs them also.
Soap Note Example 1:
Patient Name:
Robert Kryle DOB: 12/31/1961
Record No.
K-6112r809
Date:
09/09/1999
S—Pt. states that she has always been
overweight. She is very frustrated with trying to
diet. Her 20 year class reunion is next year and she
would like to begin working toward a weight loss goal
that is realistic. NKDA,
NKA.
O—WT = 210 lbs HT = 60 “ BW = 115 lbs
Chol = 255 BP = 120/75
A—Obese at 183% IBW,
hypercholesterolemia
P—Long Term Goal: Change lifestyle
habits to lose at least 70 pounds over a 12 month
period. Short Term Goal: Client to begin a 1500
Calorie diet with walking 20 minutes per day.
Instructed Pt on lower fat food choices and smaller
food portions. Client will keep a daily food and mood
record to review next session. Follow-up in one
week.
———————————————————————————
Soap Note Example 2:
Patient Name:
Lisa Brown DOB: 2/3/1960
Record No.
B-583uw809
Date:
10/19/2001
S—Pt. here for weekly BP check, no
complaints. NKDA, NKA.
O—BP 142/88; Atenolol 50 mg
daily
A—hypertension
controlled
P—Continue Atenolol; RTO 6
months
———————————————————————————
Soap Note Example 3:
Patient Name:
Lisa Brown DOB: 2/3/1958
Record No.
B-583uw809
Date:
04/21/2005
S—Pt. here for 6 mos. follow-up
visit, no complaints. NKDA, allergic to
latex
O—BP 142/88; Atenolol 50 mg
daily
A—hypertension
controlled
P—Continue Atenolol; RTO 6
months
———————————————————————————
Soap Note Example 4:
Patient Name:
Robert Dreg DOB: 09/17/1967
Record No.
D-679dk978
Date:
12/4/2007
S—Pain in left hip x 3 months; worse
when walking or doing exercise.
NKDA.
O—Wt. 195 lb, Ht. 5'5'', normal ROM
both hips, no swelling or
redness.
A—Possible osteoarthritis; R/O
rheumatoid arthritis
P—blood work—sed rate, rheumatoid
factor, x ray L hip PA and lateral; ibuprofen 600 mg
t.i.d po; recheck 2 months.
———————————————————————————
Soap Note Example 5:
Patient Name:
Paul Kessler DOB: 11/03/1961
Record No.
K-470pk624
Date:
21/8/2008
S—Mild burning with frequent
urination, a thin discharge that is worse in the A.M.,
irritation at the urinary opening at tip of penis,
NKA.
O—Discharge with gram stain negative
for gonorrhea, showing large numbers of WBCs.
Chlamydia test is positive.
A—Non-Gonorrheal
Urethritis
P—Doxycycline 100mg BID for 10 days
or Erythromycin 500mg QID for 10 days or Tetracycline
500mg QID for 10 days. Increase fluid intake, avoid
alcoholic beverages. Pt education on safe sex
practices.
———————————————————————————
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