What is a SOAP note?

A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction. Because SOAP notes are employed by a broad range of fields with different patient/client care objectives, their ideal format can differ substantially between fields, workplaces, and even within departments. However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP. A SOAP note should convey information from a session that the writer feels is relevant for other healthcare professionals to provide appropriate treatment. The audience of SOAP notes generally consists of other healthcare providers both within the writer’s own field as well in related fields but can also include readers such as those associated with insurance companies and litigation. A good SOAP note should result in improved quality of patient care by helping healthcare professionals better document and therefore recall and apply details about a specific case.

How long is a SOAP note and how do I style one?

The length and style of a SOAP note will vary depending on one’s field, individual workplace, and job requirements. SOAP notes can be written in full sentence paragraph form or as an organized list of sentences fragments. Note the difference in style and format in the following two examples. The first come from within a hospital context. The second is an example from a mental health counseling setting.

Example #1

11/1/97

S – Nauseated, fatigued

O – Less jaundiced

    Liver less tender

    Taking adequate calories and fluid

    Ultrasound liver/billary tract: normal

A – Seems to be improving

    No obstruction

P – Check liver tests tomorrow

    Phone laboratory for hepatitis markers

(from Heifferon, 2005, p. 103)

Example #2

7/7/01 2 p.m. (S) Reports counseling is not helping him get his family back. Insists the use of violence has been needed to “straighten out” family members. Reports history of domestic violence. Recent history: States he met and verbally fought with his wife yesterday regarding the privileges of oldest child. Personal history: childhood physical and mental abuse resulting in foster care placement, ages 11-18. (O) Generally agitated throughout the session. Toward the end of the session stood up, with clenched fists and jaw, angrily stated that counseling is “same old B.S.!” Rushed out of office. (A) Physical Abuse of Adult [V61.1 DSM code] and Child(ren) [V61.21]. Clinical impressions: rule out Intermittent Explosive Disorder given bouts of uncontrolled rage with non-specific emotional trigger. (P) Rescheduled for 7/14/01 @ 2 p.m.; Continue cognitive therapy. Refer to Men’s Alternatives to Violence Group. Next session, introduce use of “time-outs.” S. Cameron, Ph.D., LPCC (signature).

(from Cameron & turtle-song, 2002, p. 80).

Key Points

These examples are not the only two ways to write a SOAP note. Rather, they showcase differences in approaches for SOAP note styles. As mentioned above, different fields and even different clinics will have varied preferences and practices for writing these clinical documents.

Despite this variation, it is important to keep in mind that a SOAP note should be sufficiently detailed so that an outside healthcare provider with no previous interaction with the patient/client can obtain all the necessary information from the session or incident documented to appropriately provide care for the patient/client. Conversely, also keep in mind that efficiency and time management are important in the healthcare professions. To save both the writer and reader time, avoid overly wordy phrasing and unnecessary detail. It is perfectly acceptable and often encouraged in many settings to use abbreviations when writing SOAP notes. In some settings, especially those that use electronic healthcare records, the writer will be constrained to a predetermined number of characters that can be entered.

Abbreviations

Some commonly used abbreviations for SOAP notes are:

b/c- because

CC- chief complaint

c/o- complained of

cl- client

d/t- due to

Dx- diagnostic test

Ed- education

e.g.- exempli gratia, use when giving an example

HPI- history of present illness

i.e.- id est, use when giving alternative explanation or wording

min, mod, max- minimum, moderate, maximum

Mx- monitoring test

Rx- treatments

sx- symptoms

w/, w/o- with, without

References

Cameron, Susan & turtle-song, imani. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80, 286-292.

Heifferon, Barbara A. (2005). Writing in the health professions. New York: Pearson/Longman.