A SOAP note is a structured method of clinical documentation used by healthcare providers worldwide. The acronym stands for Subjective, Objective, Assessment, and Plan — four sections that together capture a complete picture of a patient encounter.
Originally developed by Dr. Lawrence Weed in the late 1960s as part of the problem-oriented medical record (POMR), the SOAP format has become the industry standard across medicine, nursing, physical therapy, behavioral health, veterinary medicine, and more. Its enduring popularity comes down to one thing: it works. The structured framework ensures no critical detail is missed while maintaining a logical flow from patient report to clinical decision-making.
Why SOAP Notes Matter
- Legal protection — Serves as a legal record of care delivered
- Continuity of care — Enables seamless communication between providers
- Insurance reimbursement — Required for billing and medical necessity
- Quality assurance — Supports audits, peer review, and outcome tracking
- Clinical reasoning — Forces structured diagnostic thinking
S — Subjective
This section captures the patient’s own account of their condition. Think of it as “what the patient tells you.” It includes the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and relevant past medical, family, and social history. Always document using the patient’s own language where clinically meaningful — for example, “Patient describes the pain as ‘burning and sharp.'”
O — Objective
Objective data includes everything the clinician can measure, observe, or verify. This encompasses vital signs, physical examination findings, lab results, imaging, validated assessment tools, and direct clinical observations. The key distinction: if another trained clinician could independently confirm it, it belongs in Objective.
A — Assessment
The assessment is where clinical judgment lives. This section contains your diagnosis or differential diagnosis, your interpretation of how subjective and objective findings connect, and any changes to the clinical picture since the last encounter. For established conditions, document the current status (e.g., “Type 2 diabetes — well controlled, A1c trending down”).
P — Plan
The plan outlines everything moving forward: medications prescribed, procedures ordered, referrals, patient education, lifestyle recommendations, and follow-up scheduling. A strong plan is specific and actionable — not “continue current treatment” but “continue metformin 500mg BID, recheck A1c in 3 months.”
This example demonstrates a typical outpatient follow-up for a patient with elevated blood pressure. Notice how each section builds on the last to tell a complete clinical story.
SOAP Note — Hypertension Follow-Up
Primary Care
S
Subjective
CC: Follow-up for high blood pressure.
HPI: 54-year-old male presenting for 4-week follow-up after initiating lisinopril 10mg daily for newly diagnosed hypertension. Patient reports good medication adherence with no missed doses. Denies headaches, visual changes, chest pain, or shortness of breath. Reports occasional mild dizziness upon standing in the first week, which has since resolved. Has started walking 20 minutes daily per prior counseling. Diet modifications in progress — reports reducing sodium intake but “still working on it.”
PMH: Pre-diabetes (A1c 5.9% six months ago), obesity (BMI 32).
Medications: Lisinopril 10mg daily, metformin 500mg BID.
Allergies: NKDA.
Social Hx: Non-smoker, occasional alcohol (2–3 drinks/week), sedentary occupation (desk job).
O
Objective
Vitals: BP 138/86 mmHg (seated, left arm), HR 74 bpm, RR 16, Temp 98.4°F, SpO2 98% RA. Weight: 218 lbs (down 3 lbs from last visit).
General: Well-appearing male, no acute distress.
CV: Regular rate and rhythm, no murmurs, rubs, or gallops. No peripheral edema. Bilateral pedal pulses 2+.
Lungs: Clear to auscultation bilaterally.
Labs (today): BMP — Na 141, K 4.2, Cr 0.9, BUN 14. Lipid panel — Total cholesterol 224, LDL 142, HDL 44, Triglycerides 190.
A
Assessment
1. Essential hypertension (I10) — Improving but not at goal. BP 138/86, down from 152/94 at diagnosis. Patient tolerating lisinopril well. Initial orthostatic symptoms resolved.
2. Dyslipidemia (E78.5) — New finding. LDL 142, HDL low at 44, elevated triglycerides. 10-year ASCVD risk to be calculated; likely warrants pharmacotherapy given comorbid HTN and pre-diabetes.
3. Pre-diabetes (R73.03) — Stable. Positive lifestyle changes underway. Weight trending down.
4. Obesity (E66.01) — BMI 32. 3 lb weight loss noted since initiating lifestyle modifications.
P
Plan
- Hypertension: Increase lisinopril to 20mg daily. Continue home BP monitoring; goal <130/80. DASH diet handout provided and reviewed.
- Dyslipidemia: Start atorvastatin 20mg daily at bedtime. Counseled on dietary fat modification. Recheck lipid panel in 8 weeks.
- Pre-diabetes/Obesity: Continue metformin 500mg BID. Encouraged progressive increase in daily walking to 30 minutes. Referral to registered dietitian placed.
- Patient education: Discussed cardiovascular risk factor modification. Patient verbalizes understanding of medication changes and lifestyle goals.
- Follow-up: Return in 6 weeks for BP recheck and medication tolerance assessment. Lab work 1 week prior to visit.
Mental health SOAP notes require a different emphasis. Subjective findings carry more weight, objective data relies heavily on validated screening tools and behavioral observations, and the plan often centers on therapeutic interventions rather than pharmacology.
SOAP Note — Generalized Anxiety Disorder
Behavioral Health
S
Subjective
CC: “I can’t stop worrying about everything — it’s exhausting.”
HPI: 32-year-old female presenting for 6th session of CBT for generalized anxiety disorder. Patient reports anxiety has been “moderately better” since starting thought-record exercises last session. Identifies work deadlines as primary trigger this week. Reports 2 panic-like episodes (rapid heartbeat, shortness of breath, sense of dread) — down from 4–5 per week at treatment onset. Sleep has improved from 4–5 hours to approximately 6 hours nightly but reports difficulty falling asleep on nights before work. Denies suicidal ideation, self-harm urges, or substance use. Reports practicing diaphragmatic breathing “most days” with some benefit.
Social context: Lives with partner, who is described as supportive. Recently promoted at work, which has increased responsibility and stress.
O
Objective
Appearance: Appropriately dressed, adequate hygiene. Fidgeted with hands intermittently during session.
Behavior: Cooperative and engaged. Eye contact appropriate. Speech rate mildly pressured at session start, normalizing by mid-session.
Mood: “Anxious but hopeful” (patient’s words).
Affect: Congruent with stated mood; mildly anxious, full range.
Thought process: Linear, goal-directed. No loose associations.
Thought content: Ruminative worry about work performance. No SI/HI, no delusions, no hallucinations.
Cognition: Alert and oriented x4. Judgment and insight good — patient demonstrating increased ability to identify cognitive distortions.
GAD-7 Score: 12 (moderate) — down from 18 (severe) at intake.
A
Assessment
Generalized Anxiety Disorder (F41.1) — Responding to CBT. Clinically meaningful reduction in GAD-7 (18 → 12). Panic-like episodes decreasing in frequency. Patient demonstrating improved cognitive flexibility and applying coping strategies between sessions. Sleep disturbance persists as residual symptom, likely maintained by anticipatory anxiety related to work. Risk level: low. Protective factors include strong social support, treatment engagement, and growing insight.
P
Plan
- Therapeutic focus: Introduce cognitive restructuring techniques targeting work-performance worry schemas. Assign graded exposure exercise: delegate one small task at work without checking the outcome.
- Sleep intervention: Introduce stimulus control and sleep restriction strategies. Provided sleep hygiene psychoeducation handout. Limit caffeine after 12 PM.
- Homework: Continue daily thought records with focus on identifying “should” statements. Practice 4-7-8 breathing technique before bed nightly.
- Medication: Not currently indicated. Will reassess if GAD-7 plateaus above 10 after 4 additional sessions.
- Follow-up: Next session in 1 week. Re-administer GAD-7 at next visit.
Physical therapy SOAP notes emphasize functional outcomes, measurable progress, and exercise prescription. Range of motion (ROM), strength grades, and functional scores are critical objective data points.
SOAP Note — ACL Reconstruction Rehab
Physical Therapy
S
Subjective
CC: Post-op rehab, 6 weeks status post right ACL reconstruction (hamstring autograft).
Patient reports right knee pain at 3/10 at rest, increasing to 5/10 with prolonged standing. States swelling has “gone down a lot” compared to last week. Reports compliance with home exercise program (HEP) 5 out of 7 days. Able to walk without crutches around the house for short distances but feels “unsteady” on uneven surfaces. Denies any locking, giving way, or new popping sensations. Goal: return to recreational soccer within 9 months.
O
Objective
Observation: Mild effusion right knee, decreased from moderate at last visit. Incision well-healed, no erythema. Antalgic gait pattern with shortened stance phase on right.
AROM Right Knee: Flexion 118° (previous: 105°), Extension −3° (previous: −5°). Left knee: 0°–140° for reference.
Strength (MMT): Right quadriceps 3+/5, hamstrings 4−/5, hip abductors 4/5. Left: 5/5 throughout.
Special tests: Lachman — firm endpoint, 1+ translation (expected post-graft). Negative posterior drawer.
Patellar mobility: Slightly restricted medial glide.
Functional: Single-leg stance R: 8 sec (L: 30+ sec). Timed Up-and-Go: 11.2 sec.
Pain with treatment: 4/10 during terminal knee extension mobilization, resolving to 2/10 post-treatment.
A
Assessment
Status post R ACL reconstruction (S83.511A) — Progressing well at 6 weeks post-op. ROM gains significant (13° flexion improvement in one week). Quad strength remains primary deficit limiting functional recovery. Effusion continues to decrease. Patient motivated and compliant with HEP. Ready to advance to Phase 2 rehabilitation protocol (closed kinetic chain strengthening, proprioceptive training). Short-term goal: achieve 0°–130° AROM and 4/5 quad strength by week 10. Long-term goal: return to sport by 9 months post-op pending functional testing clearance.
P
Plan
- Manual therapy: Patellar mobilization (medial/lateral glides), soft tissue mobilization to quad and hamstring, Grade III tibiofemoral joint mobilization for terminal extension.
- Therapeutic exercise: Progress to mini squats (0–60°), leg press (0–70°), standing hip abduction with band, prone hamstring curls. Initiate balance board bilateral stance.
- Modalities: Cryotherapy post-session. Discontinue NMES per protocol — patient achieving voluntary quad contraction.
- HEP update: Add mini squats 3×10, single-leg balance on firm surface 3×30 sec. Continue heel slides and quad sets.
- Follow-up: 2x/week for 4 weeks. Reassess ROM and strength at week 10 visit. Coordinate with orthopedic surgeon at 3-month post-op appointment.
Emergency medicine SOAP notes prioritize rapid documentation, differential diagnosis reasoning, and disposition decisions. Time-stamping and ruling out critical diagnoses are essential elements.
SOAP Note — Acute Chest Pain Evaluation
Emergency Medicine
S
Subjective
CC: “Chest pain that woke me up at 3 AM.”
HPI: 48-year-old male presenting to ED at 04:15 via private vehicle with substernal chest pain. Onset approximately 1 hour prior to arrival. Describes pressure-like pain, 7/10 severity, radiating to left arm and jaw. Associated with diaphoresis and nausea (no emesis). No relief with position changes. No prior episodes. Denies recent illness, trauma, immobilization, or leg swelling.
PMH: Hyperlipidemia (not on medication — patient declined statin 1 year ago), family hx of MI (father at age 52). Former smoker (1 PPD × 15 years, quit 5 years ago).
Medications: None. Allergies: Sulfa (rash).
O
Objective
Vitals (04:20): BP 158/94, HR 102, RR 20, Temp 98.6°F, SpO2 97% RA.
General: Anxious, diaphoretic male clutching chest. Moderate distress.
CV: Tachycardic, regular rhythm. No murmurs, rubs, or gallops. No JVD. No peripheral edema.
Lungs: Clear bilaterally. No crackles or wheezing.
Abdomen: Soft, non-tender, non-distended.
Extremities: No calf tenderness, no asymmetric swelling.
ECG (04:25): Sinus tachycardia at 102 bpm. ST elevation 2mm in leads II, III, aVF with reciprocal ST depression in I, aVL. Consistent with acute inferior STEMI.
Labs (04:30): Troponin I 0.85 ng/mL (ref <0.04). CBC, BMP, coags within normal limits.
A
Assessment
1. Acute ST-elevation myocardial infarction — inferior (I21.19) — ECG and troponin confirm diagnosis. HEART score 9 (high risk). Door-to-ECG time: 10 minutes.
2. Hypertension, likely stress-related in acute setting
3. Hyperlipidemia, untreated — contributing risk factor
P
Plan
- STEMI protocol activated (04:28): Cardiology/interventional cardiology emergently consulted. Cath lab team mobilized. Target door-to-balloon <90 minutes.
- Acute management: ASA 325mg PO chewed (administered 04:22). Heparin bolus 60 units/kg IV, drip at 12 units/kg/hr. Ticagrelor 180mg PO loading dose. Morphine 4mg IV for pain. Ondansetron 4mg IV for nausea.
- Monitoring: Continuous cardiac telemetry. Serial vitals q15min. Repeat 12-lead ECG post-intervention.
- Disposition: Emergent transfer to cardiac catheterization lab for percutaneous coronary intervention (PCI). Anticipated admission to CCU post-procedure.
- Family notification: Spouse contacted and en route. Risks and plan discussed; verbal consent obtained for emergent PCI.
| Element |
Primary Care |
Mental Health |
Physical Therapy |
Emergency Med |
| Subjective emphasis |
HPI, medication review, lifestyle |
Patient’s emotional state, triggers, coping |
Pain levels, functional limitations, HEP compliance |
Onset, severity, associated symptoms, timing |
| Key objective data |
Vitals, PE findings, lab results |
MSE, screening tools (GAD-7, PHQ-9) |
ROM, MMT, gait analysis, functional tests |
Vitals, ECG, imaging, labs (time-stamped) |
| Assessment style |
Problem list with ICD-10 codes |
Diagnostic impression, risk assessment |
Functional progress toward goals |
Differential diagnosis, rule-outs |
| Plan focus |
Medications, referrals, follow-up |
Therapeutic interventions, homework |
Exercise Rx, modalities, HEP |
Acute interventions, disposition |
| Typical length |
1–2 pages |
1 page |
1–1.5 pages |
1–2 pages |
Documentation Pitfalls
- Mixing subjective and objective data — Placing your clinical observations in the Subjective section or putting patient quotes in Objective undermines the note’s logical structure.
- Vague assessments — Writing “patient is doing better” without specifying how, by what measure, or compared to what baseline makes the note clinically useless.
- Copy-forward syndrome — Blindly carrying notes from previous visits creates inaccurate records and is a leading cause of audit flags.
- Non-actionable plans — “Continue current management” provides no clinical value. Specify doses, frequencies, timelines, and contingencies.
- Missing timelines — Omitting symptom duration, follow-up intervals, or medication start dates creates gaps in the clinical narrative.
- Insufficient differential diagnosis — In urgent/emergent settings, failing to document considered and excluded diagnoses exposes providers to liability.
- No patient education documentation — If you counseled the patient, document it. Undocumented education is legally considered education that didn’t happen.
These evidence-based strategies will help you write SOAP notes that are clinically useful, legally sound, and time-efficient.
Best Practices
- Use the patient’s own words for the chief complaint — it provides clinical context and protects against assumptions.
- Quantify everything possible — pain scales, ROM in degrees, number of episodes, percentage improvement.
- Time-stamp critical events — especially in acute care. “04:25 ECG obtained” is infinitely more useful than “ECG obtained.”
- Link your Assessment to specific S and O findings — your reasoning should be traceable.
- Write the Plan as if someone else will execute it — include enough detail that a covering provider could follow through.
- Document informed decision-making — note when patients decline recommendations or choose alternative treatments.
- Use standardized abbreviations — avoid non-standard shorthand that could be misinterpreted.
- Complete notes within 24 hours — accuracy degrades rapidly with time, and late documentation raises compliance concerns.
What is the difference between a SOAP note and a DAP note?
A DAP note (Data, Assessment, Plan) combines the Subjective and Objective sections into a single “Data” section. It’s commonly used in behavioral health settings where the distinction between patient-reported information and clinician observations is less rigid. SOAP notes provide more granular separation, making them preferred in medical, surgical, and rehabilitation settings where objective clinical measurements are critical.
How long should a SOAP note be?
There is no universal length requirement. A focused follow-up visit might produce a half-page note, while a complex new patient evaluation could run two pages. The guiding principle is clinical adequacy: your note should contain enough detail to reconstruct your clinical reasoning, justify your billing code, and enable another provider to continue care — but no more.
Can I use SOAP notes for telehealth visits?
Yes. SOAP notes work well for telehealth encounters with minor modifications. In the Objective section, note the modality (video, phone) and document what you could and could not assess remotely. Many payers and regulatory bodies require documentation of the technology platform used and confirmation that the patient consented to the telehealth format.
Are SOAP notes required by law?
While no federal law mandates the SOAP format specifically, healthcare providers are legally required to maintain adequate clinical documentation. The SOAP format is widely accepted as meeting this standard and is the expected format for most insurance reimbursement, accreditation bodies (e.g., Joint Commission), and state licensing boards.
How do SOAP notes support medical billing and coding?
SOAP notes provide the documentation foundation for medical billing. The Subjective and Objective sections establish the complexity of the visit (supporting E/M code selection), the Assessment provides the diagnosis codes (ICD-10), and the Plan documents medical necessity for ordered tests, treatments, and referrals. Inadequate documentation is the most common reason for claim denials and audit clawbacks.
What EHR systems support SOAP note formatting?
Nearly all major EHR platforms support SOAP-structured documentation, including Epic, Cerner (Oracle Health), Athenahealth, DrChrono, Practice Fusion, SimplePractice (for behavioral health), and WebPT (for physical therapy). Most offer customizable SOAP templates and smart phrases to accelerate documentation.
