Today, we’ll be stepping away from literal soap and leaping into the world of medical documentation. While you wave goodbye to your rose and ice cream-shaped soaps for now, you might be wondering — what exactly are SOAP notes? 

The term itself comes from the implementation of a Subjective, Objective, Assessment, and Plan portion in each note, hence the S.O.A.P. acronym. Depending on each specific branch of healthcare, SOAP notes are slightly different. However, every SOAP note will contain the 4 hallmark sections that make up the term. 

SOAP notes are most often used in the mental health niche, but can be seen in fields like physical therapy and nursing as well. The end goals of SOAP notes are for practitioners to better recall previous patient information and as a simple means of sharing documents with other involved parties. Transitioning from regular notes to SOAP notes can promote more one-on-one time with patients, reduce misunderstandings, and will produce better outcomes for both you and your patients. 

To learn the in’s and out’s of SOAP notes — we urge you to keep reading. We’ll be covering proper SOAP note formatting, examples of SOAP notes across industries, and offer a general template for you! 

The S.O.A.P. Note Format 

Subjective, Objective, Assessment, and Plan will serve as the headings in your SOAP note. To obtain the most relevant information for your SOAP notes, here’s what should go under each heading:  

• Subjective —  This section is about your client’s or a relevant third party’s opinions and perspectives. Subjective information from other relevant sources (e.g. caretaker, guardian, etc.) needs to be labeled as such. You may want to document the patient’s general information here as well. This general information may include name, gender, age, and the reason for visiting. 
• Objective — Here, you’ll want to document relevant medical history, recent diagnostic tests, and other facts. If a physical or mental assessment is conducted during the visit, include the results of those. 
• Assessment — Under this heading, you’ll want to synthesize the subjective and objective sections to come to a professional diagnosis. If a diagnosis was already made previously, you will want to discuss changes in the status of the diagnosis or a new diagnosis. 
• Plan — The last section will outline future plans based on the problems you have identified. Outline examples may include additional testing or consultations with other experts as part of the treatment. 

In terms of writing style, you are able to write however you want. That includes full paragraphs, bullet points, or even fragments. The only requirement is that you convey your writing in a clear and concise manner that’s easily understood by your future self and others.