A SOAP note is a method of documentation used by healthcare providers such as physicians, nurses, therapists, mental health practitioners, etc., to document their interactions with their patients, their assessment, and the treatment plan or recommendations.
The SOAP note format, a key component of the Problem-Oriented Medical Record (POMR), was developed in the 1960s by Lawrence Weed, a professor of medicine and pharmacology at the University of Vermont. His method became popular over time and became the most common method of documentation in healthcare settings and is the basis for our template.
Because of the many uses this simple yet detailed document offers, we’ve developed a free downloadable SOAP note template that can be tailored to different healthcare specialties and situations. This template offers a simple solution to the common problems of inconsistent documentation, time-consuming note-taking, and difficulty tracking patient progress over time.
Below, we’ve also detailed the key components of a SOAP note (the SOAP note language), how to fill the different sections, why each section is important, and practical examples, to help you better utilize the template we’ve provided when dealing with patients.
What does the SOAP Note Template Include?
The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Basically, the entire document that you will create to treat your patients is based on these four terminologies.
While the length and information to be included in the document may differ based on discipline and how the patient presents, the format follows the same basic structure:
Subjective
This is the first item included in the template. It should detail the patient’s main complaint. This can include direct quotes from the patient or their family, their symptoms, and how the problem affects them. The main purpose of this section is to clearly understand and record all the issues, symptoms, and other factors affecting the patient according to what they say or the symptoms they present during the visit.
To complete this section, focus on these three aspects, i.e., the main complaint as registered by the patient or their family members; the development of the illness, i.e., onset, location, duration, characterization, severity, etc., and history, i.e., medical history, current medications, allergies, etc.
Objective
This section should include the practitioner’s observation of the patient’s behavior and documentation of other measurable data from the patient through instruments, reports, and examinations. Some of the things are vital signs, lab tests, appearance and demeanor, speech patterns, mental status assessment findings, behavior, etc.
The template we’ve provided also includes an anatomical body diagram featuring posterior, anterior and lateral views of the human form. The diagram has six symbols, i.e., Adhesion, Rotation, Elevation, Spasm, Hypertonicity and Tender Point. All these symbols are included to help you make precise markings of any physical findings that your patient presents with.
When using this diagram for your Objective documentation, start with a systematic approach to marking your findings. Observe the patient and note any obvious asymmetries, discolorations, or swelling patterns – use the provided symbol key in the diagram.
As you conduct your examination, make sure to mark your findings in real time, rather than from memory after the examination. Each symbol you use should correspond to specific clinical findings from your examination.
Assessment
This is the third section of the template. It should contain the professional evaluation of the patient’s condition as captured in the subjective and objective sections. To document this section, consider critically analyzing the first two sections by going through their complaint and how they responded to basic or, if applicable, comprehensive treatment.
Consider correlating all the subjective notes with the objective records, detailing possible interactions of the issue in the case, and noting any changes or new developments in the patient’s overall health over time.
Plan
This section of the SOAP note template is to address the plan of care – what are your intended actions moving forward? This section details the treatment strategies, recommends long- and short-term interventions, and discusses any necessary adjustments to the patient’s treatment or care plan. When completing this section, be specific on what you expect the patient to do and state your expectations for the duration of the treatment.
Available Formats
We have provided this SOAP note template in several document formats: Google Docs, Word Document, Word Template, and ODT.
Tips For Writing SOAP Notes
- Use proper terminologies: Use medical terminologies and abbreviations that are widely recognized in your field.
- Document objective data: Document all measurable and observable facts. Include all vital signs, physical examination findings, and test results.
- Be culturally sensitive: When documenting patient information, be aware of and respectful of cultural differences. Use culturally appropriate language, and avoid making assumptions or being stereotypical.
- Link the assessments to findings: Relate your assessments and/or diagnosis to the subjective and objective sources of information that you have captured. The rationale for how patients were managed, why you reached certain decisions, and how your findings support that are clear.
- Give a clear plan: Develop a comprehensive plan of treatment and care that will enable the management of all the highlighted factors. Include all the interventions, recommendations, or follow-up instructions.
A Quick Word
Maintaining clear documentation across various clinical scenarios can be challenging for most healthcare professionals. Whether you are a physician, a specialist conducting follow-up consultations, or a mental health therapist, using a standard template like the one we’ve provided to document all your patient encounters is important. This is because clear documentation of a patient’s case can enhance the continuity of care, and improve communication between you, the patient and other healthcare providers. Using this template can also help ensure that you remain legally compliant.
