the soap note format

The SOAP Note FormatThe letters SOAP is an acronym. The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN. Many medical offices use the SOAP note format to standardize medical evaluation entries made in patient records. The SOAP note improves communication beween all caring for the patient. It displays the assessment, problems and plans in an organized format and facilitates better medical care when used.

SOAP Note DocumentationMedical documentation of patient complaint(s) and treatment must be consistent, concise and comprehensive. In your role as a medical assistant it is important that everything that needs to be documented in a patient's chart is DOCUMENTED and that it is done in the right format and tone! Always remember: the patient's medical record is a legal document. And whatever wasn't documented = never happened. This omission could become detrimental under certain circumstances and is intended to protect everybody involved.

The SOAP note documentation 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

SOAP Note Writing

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.

SOAP Note Examples

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.

An 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 you experiment and become more proficient in your routine you will eventually develop your preferred technique to remain short and accurate.

Medical Assistant SOAP Note Writing >> SOAP Note Review

In your role as a medical assistant you will take vital signs, height, and weight measurements and enter it into the medical record under the "Objective" SOAP.

Medical Assistant SOAP Note Examples | SOAP Note Parts

See the four parts of a SOAP note and examples how a medical assistant is allowed to enter them in a patient's record. SOAP note Example 1, SOAP note Example 2...

SOAP Note Parts

SUBJECTIVE — The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by an accompanying relative or significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes.

OBJECTIVE — The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

ASSESSMENT — Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

PLAN — The last part of the SOAP note is the health care provider's plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and follow-up directions for the patient.

Medical Assistant SOAP Notes

Examples are as a medical assistant would enter the patient's demographics, and subjective, and objective segment into a patient's record. The assessment and plan is written by the doctor. The entries are initialed by the medical assistant, while the provider signs them also.

Abbreviations key: WT = weight HT = height IBW = ideal body weight BP = blood pressure Chol = cholesterol Pt = patient RTO = Return to office ROM = range of motion R/O = rule out PA= posterior/anterior

NKDA = No known drug allergies NKA = No known allergies P = pulse Temp or T = temperature BS = blood sugar UA = urinalysis VA = vision acuity O.S. = left eye O.D. = right eye O.U. = both eyes

Writing the SOAP Note

Soap Note Example 1:

Patient Name: Robert Kryle DOB: 12/31/1961 Record No. K-6112r809 Date: 09/09/1999

S—Pt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next year and she would like to begin working toward a weight loss goal that is realistic. NKDA, NKA.

O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75

A—Obese at 183% IBW, hypercholesterolemia

P—Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one week. ——————————————————————————— - B. Ridman, CCMA M. Myer, MD


Patient Name: Lisa Brown DOB: 2/3/1960 Record No. B-583uw809 Date: 10/19/2001

S—Pt. here for weekly BP check, no complaints. NKDA, NKA. O—BP 142/88; Atenolol 50 mg daily A—hypertension controlled P—Continue Atenolol; RTO 6 months ——————————————————————————— - M.T., CMA Carlos Monila, MD



S—Pt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex O—BP 142/88; Atenolol 50 mg daily A—hypertension controlled P—Continue Atenolol; RTO 6 months ——————————————————————————— - Daisy Rodriguez, CCMA Paula Klein, MD


Patient Name: Robert Dreg DOB: 09/17/1967 Record No. D-679dk978 Date: 12/4/2007 S—Pain in left hip x 3 months; worse when walking or doing exercise. NKDA. O—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness. A—Possible osteoarthritis; R/O rheumatoid arthritis P—blood work—sed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2 months. ——————————————————————————— - B. Ridman, CCMA Brenda D. Fisgers, MD


Patient Name: Paul Kessler DOB: 11/03/1961 Record No. K-470pk624 Date: 21/8/2008 S—Mild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening at tip of penis, NKA.

O—Discharge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is positive. A—Non-Gonorrheal Urethritis P—Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for 10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices. ——————————————————————————— - R. W., RMA Ted Ricca, MD

What is a SOAP Note?http://www.medicalassistant.net/soap_note.htm Writing a SOAP Notehttp://www.medicalassistant.net/writing_a_soap_note.htm

What is a SOAP Note?SOAP notes are written into the patient's medical record during the course of a physical or medical examination by the physician and other licensed health care providers. This entry serves as a permanent record of a patient's condition and treatment for future reference. With correct training and proper supervision a medical assistant is allowed to briefly interview the patient and enter the patient's reason for the visit under the "Subjective" line of the SOAP note.

Think about it! The health care industry is booming and you want to land a better job… but with a large number of other medical assistants applying for the same jobs and competing with you, you HAVE to your part to set yourself apart from the rest, or otherwise you may quickly find yourself left behind.

When is the SOAP Note Written? The reason for the visit is entered into the "Subjective" (S) of the SOAP note exactly as

the patient stated. As the medical assistant takes the patient's vital signs, height, and weight measurements it

can be entered into the medical record under the "Objective" area (O) to be reviewed minutes later by the physician.

The medical assistant may also ask about medications taken, and whether the patient has any known allergies to environmental substances, food, or medicines.

The patient's response is also listed carefully and accurately under the "O" part of the SOAP note.

REMEMBER: The medical assistant NEVER writes the "Assessment" (A) or the "Plan" (P) in a SOAP note, but should be able to understand this vital part of the medical record entry when reviewing the patient's chart.

SOAP Note Writing Tips:

1. You should start your entry into the medical record right after the last note in the chart so it will always be in chronological sequence.

2. It is okay to be bold in your presentations, but conservative when charting.3. Since the patient's medical record is a legal document write fluently and legibly and do

not leave blank lines in between the text. This is to prevent someone else from writing additional information or comments into your original note. If you made a mistake, simply cross out the unwanted part of the sentence, whether its just one word or several sentences, with a single horizontal line. Then write “error” next to or above the corrected area and initial it.

4. Never scribble over any part of the note, or use "white-out" to cover a mistake. Those who read and examine a medical record must be able to see mistakes and know who is responsible for crossing a word or sentences out.

5. For neatness' sake you may want to start at the top of a page and avoid too much (any) blank space above your note. You should also provide room for the doctor, to amend and initial your note at the end.

Soap Note Examples

Last but not least: always sign your notes after your printed name and include your professional title or credentials. Once again, always leave room on the same page for your notes to be amended and cosigned by the physician under whose supervision you are working. This is important for both medico-legal purposes and so others can contact you with questions about what you have written.

What is a SOAP Note?http://www.medicalassistant.net/soap_note.htm


Patient Name: Robert Kryle DOB: 12/31/1961 Record No. K-6112r809

Date: 09/09/1999

S—Pt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next year and she would like to begin working toward a weight loss goal that is realistic. NKDA, NKA.

O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75

A—Obese at 183% IBW, hypercholesterolemia

P—Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one week. ——————————————————————————— - B. Ridman, CCMA M. Myer, MD


Patient Name: Lisa Brown DOB: 2/3/1960 Record No. B-583uw809 Date: 10/19/2001 S—Pt. here for weekly BP check, no complaints. NKDA, NKA. O—BP 142/88; Atenolol 50 mg daily A—hypertension controlled P—Continue Atenolol; RTO 6 months ——————————————————————————— - M.T., CMA Carlos Monila, MD



S—Pt. here for 6 mos. follow-up visit, no complaints. NKDA, allergic to latex O—BP 142/88; Atenolol 50 mg daily A—hypertension controlled P—Continue Atenolol; RTO 6 months ——————————————————————————— - Daisy Rodriguez, CCMA Paula Klein, MD


Patient Name: Robert Dreg DOB: 09/17/1967 Record No. D-679dk978 Date: 12/4/2007 S—Pain in left hip x 3 months; worse when walking or doing exercise. NKDA. O—Wt. 195 lb, Ht. 5'5'', normal ROM both hips, no swelling or redness. A—Possible osteoarthritis; R/O rheumatoid arthritis P—blood work—sed rate, rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2 months. ——————————————————————————— - B. Ridman, CCMA Brenda D. Fisgers, MD


Patient Name: Paul Kessler DOB: 11/03/1961 Record No. K-470pk624 Date: 21/8/2008 S—Mild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening at tip of penis, NKA. O—Discharge with gram stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is positive. A—Non-Gonorrheal Urethritis P—Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for 10 days. Increase fluid intake, avoid alcoholic beverages. Pt education on safe sex practices. ——————————————————————————— - R. W., RMA Ted Ricca, MD

the soap note format

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