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!
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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.
SOAP Notes Examples
The best way to learn and understand the concept of writing a SOAP note is by looking at some examples!
Nursing SOAP Notes
Subjective — Ms. Bell is a 34-year-old female coming in for chronic chest pain. She ranked her pain score a 2/10, claiming that there’s more tightness than pain. She mentions that her family has a history of high blood pressure. Currently, she’s taking 2 Ibuprofen tablets to relieve the pain/tightness.
Objective — Client is sweating when she enters the room. When checked, her blood pressure is 145/80. When inspected, her resting heart rate was slightly faster than normal as well. A previous blood test confirms the high blood pressure, and she is otherwise healthy.
Assessment — It is likely that her chronic chest pain is a symptom of angina, and it will need to be addressed. The patient may be at risk if her blood pressure is not handled responsibly. Further testing will be required to rule out other issues.
Plan — Currently, Ms. Bell is instructed to eat healthier, get 30 minutes of exercise a day, and drink at least 10 glasses of water a day. Awaiting cardiology consultation for further examination and a proper diagnosis.
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Mental Health SOAP Notes
Subjective — Brett is a 19-year-old male struggling to sleep at night. Currently taking no medications, there are no genetic factors to be concerned about, and he is otherwise healthy.
Objective — Patient is biting his nails. When instructed to sit, he is reluctant to do so. He is excessively sweating and he is fidgety.
Assessment — Patient matches several indicators of generalized anxiety, and needs to learn tactics to reduce stress. His trouble sleeping is likely linked to stress and will need to be confirmed.
Occupational Therapy SOAP Notes
Subjective — Mr. Smith is a 55-year-old man coming in for scheduled occupational therapy. His caretaker reports that he is still struggling for balance, but has improved slightly. Mr. Smith says “I want to go home” to his caretaker.
Objective — When working on balance exercises, Mr. Smith was able to finish 4 seconds faster than his previous attempt 2 days ago. However, his tendency to lean to the right remains the same as before.
Assessment — The patient is still demonstrating a skewed center of gravity and a lack of postural control. Improvements are occurring but not as fast as previously anticipated.
Plan — Increase OT meeting frequency from 2 to 3 times a week. Provide clients with posture improvement equipment for daily use at home. Instructed to focus use stay mindful of his balance throughout the day.
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Social Work SOAP Notes
Subjective — Forrest is a 12-year-old male who is legally blind and starting middle school in the Fall. He feels nervous that he’ll be attending a public school, but is excited to make new friends and learn new skills.
Objective — A recent eye report reveals 20/200 for both eyes when wearing corrective lenses. He has already been tested and has Retinitis Pigmentosa.
Assessment — Forrest will need to strengthen his advocacy skills so that teachers can properly accommodate his needs. Consult previous teachers about Forrest and how he is in school.
Plan — Schedule bi-weekly meetings with Forrest to work on advocacy and independence skills.
Counseling SOAP Notes
Subjective — Mariam is a 22-year-old female coming in due to a recent tragedy. This is her second appointment. Her husband is concerned because Mariam barely talks anymore and has started drinking as a coping mechanism.
Objective — Client is slumped over in her chair and is visibly upset. She has not said a word since her husband left the room. When asked “how are you doing today?”, there was no verbal or body response.
Assessment — The patient needs to develop better communication skills regarding the recent tragedy. This may help her come to terms and garner support from friends and family close to her.
Pediatric SOAP Notes
Subjective — Sarah is a 5-year-old who is brought in by her mother, and is suffering from left-side ear pain. Sarah ranks her pain a 7/10 and claims that the pain has been getting worse the last few days. Her mother thinks the pain started after a trip to the beach about a week ago.
Objective — Pneumatic otoscope was used and fluid is present behind the left eardrum.
Assessment — The fluid and the pain confirm that Sarah has an ear infection.
Plan — Prescribe Amoxicillin for 7 days to deal with infection. Schedule a follow-up appointment in 7 days for progress update.
Physical Therapy SOAP Notes
Subjective — Tim is a 20-year-old male coming in for shoulder crepitus and pain. He reports going to the gym several times a week. Overhead movements irritate both shoulders, causing a creaking and popping sound. For his right shoulder, he reports no pain. For his left shoulder, he reports a 2/10 pain level.
Objective — Patient lacks flexibility when testing shoulders. When instructed to reach overhead, an audible popping noise is heard. The popping originates from both rotator cuffs. The popping on the left is louder than on the right.
Assessment — The patient may be experiencing early stages of rotator cuff tears. These problems need to be treated to prevent further complications.
Plan — Provide the patient with 2lb weights and will work with him to perform rotator cuff strengthening exercises. Focus on stretching before and after performing the strengthening exercises.
SOAP Notes Template
Here’s a template of what to include in each section of your SOAP note. Depending on your branch of healthcare, some bullet points are not necessary to cover.
- Theme — Patient observations, opinions, and experiences
- History of Present Illness: Structured as onset, location, duration, characterization, alleviating and aggravating factors, radiation, temporal factors, and severity (OLD CARTS)
- Patient history: Medical, surgical, social, and genetic factors
- Allergies and current medications
- Other symptoms
- Theme — Physical exam and laboratory data
- All pertinent labs: Examples include results of x-rays, brain scans, or physical exams that were performed during the session
- Vital signs if recorded
- Theme — Educated diagnosis
- Assessment: One sentence detailing the patient and their main diagnosis. The diagnosis will need to have a proper rationale behind it.
- Problem list (if applicable): Detail other problems, along with the rationale behind each.
- Theme — Further actions towards treatment
- Further actions (e.g. more testing or consultations, prescribing medications, providing education resources)
- Complimentary or alternative solutions
- Follow up plans with patient