What is a SOAP Note?

Many medical offices use the SOAP note format to standardize medical evaluation entries made in clinical records. The SOAP note is written to improve communication among all those caring for the patient to display the assessment, problems and plans in an organized format.

ATTENTION: Always remember that the patient's medical record is a legal document.

Medical documentation of patient complaint(s) and treatment must be consistent, concise and comprehensive, so do it right! The SOAP Note should briefly express the following:

• Date and purpose of the visit
• The patient’s symptoms and complaints
• The current physical exam: patient's height, weight, temperature, pulse, blood pressure, visual acuity, etc.
• New lab data and results of studies, reports, assessments
• The current formulation and plan for the patient

What Does SOAP Mean?

SOAP is an acronym. The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN. Writing SOAP notes facilitates better care of the patient when used in the patient's record for review and quality control.

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SOAP Note Content - Length - And Purpose

The SOAP note is not supposed to be as detailed as a progress report. Complete sentences are not necessary and abbreviations are appropriate. However, avoid them until you have a handle on how the abbreviations are used—they differ for each specialty and are consistent within the medical office where you work. See The Four Parts of a SOAP Note.

The length of the note will differ for each specialty as well. SOAP notes can be flexible. You will develop your own style as you try to accommodate office preferences. The note written by a novice will usually turn out to be a little longer than that of the more advanced staff with more clinical judgment and experience in proper SOAP note writing format. It is practice that makes perfect.

The inexperienced writer will often give more thought as to what to write and usually will wind up putting more of what they have observed to paper than necessary. A short, but precise SOAP note is often better than an entry that is too verbose. As medical assistants experiment and become more proficient, they eventually develop their preferred technique to remain short and accurate.