What Each Section of a SOAP Note Means

Each section of a SOAP note requires certain information, including the following:

Subjective: SOAP notes all start with the subjective section. This refers to subjective observations that are verbally expressed by the patient, such as information about symptoms.

It is considered subjective because there is not a way to measure the information. For example, two patients may experience the same type of pain. One patient may report it as the worst pain of their life while another may say it was only moderate pain.

When considering what to include in the subjective section of your SOAP notes remember the mnemonic OLDCHARTS. Each letter stands for a question to consider when documenting symptoms. Consider the following:

– Onset: Determine from the patient when the symptoms first started.

– Location: If pain is present, location refers to what area of the body hurts.

– Character: Character refers to the type of pain, such as stabbing, dull or aching.

– Alleviating factors: Determine if anything reduces or eliminates symptoms and if anything makes them worse.

– Radiation: In addition to the main source of pain, does it radiate anywhere else?

– Temporal patterns: Temporal pattern refers to whether symptoms have a set pattern, such as occurring every evening.

– Symptoms associated: In addition to the chief complaint, determine if there are other symptoms.

Objective: The second section of a SOAP note involves objective observations, which means factors you can measure, see, hear, feel or smell. This is the section where you should include vital signs, such as pulse, respiration and temperature. Information from a physical exam including color and any deformities felt should also be included. Results of diagnostic tests, such as lab work and x-rays can also be reported in the objective section of the SOAP notes.

Assessment: The next section of a SOAP note is assessment. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong. There may also be other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment.

Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient’s problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work.