Key Takeaways

• SOAP notes provide a standardized framework that transforms complex patient interactions into clear, actionable medical documentation. 

• Effective SOAP notes require a balance of detailed observation and concise reporting.

• Mastering SOAP notes is an ongoing process. By continuously refining documentation skills, seeking feedback, and staying updated on best practices, healthcare professionals can enhance the quality of patient care and medical communication.

SOAP notes are an important documentation method that turns patient interactions into clear, comprehensive medical records. 

Whether you're a seasoned healthcare professional or a student entering the medical field, mastering SOAP notes helps to provide exceptional patient care, ensuring accurate diagnoses, and maintaining clear communication across healthcare teams.

By systematically organizing patient information, SOAP notes help healthcare providers track patient progress, make informed decisions, and create cohesive treatment plans that address individual patient needs.

What Are SOAP Notes?

SOAP notes are a structured method of documentation used by healthcare professionals to write out patient information in a clear, organized manner. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan - a systematic approach that ensures comprehensive patient care documentation.

Understanding the Chief Complaint

A chief complaint is the primary reason a patient seeks medical or psychological care. It represents the patient's main health concern, stated in their own words, and serves as the critical starting point for medical assessment and diagnosis. 

This initial statement gives healthcare providers the first glimpse into the patient's current health status and primary medical or psychological challenge.

The chief complaint serves as the critical entry point in the Subjective (S) section of a SOAP note, providing the essential context for the entire medical or therapeutic documentation process. 

Examples of Chief Complaints in Mental Health

• "I've been feeling overwhelmed and anxious for the past few weeks.”

• "I'm constantly feeling down and lacking energy, even when I try to push through."

• "I can't stop worrying about everything, and it's affecting my daily life."

• "I’ve been having trouble sleeping because I can't stop thinking about my problems."

  
  

Breaking Down the SOAP Note Structure

1. Subjective (S)

The subjective section captures the patient's personal account of their condition. This includes the patient's symptoms, personal feelings about their health, reported pain levels, medical history details, and personal observations about their current health status.

Example Subjective Entry:

Patient Sarah Thompson, 32, reports increased anxiety symptoms over the past month. She describes experiencing frequent panic attacks, particularly in social situations. Patient states, "I'm constantly worried about being judged by others.

I've been avoiding team meetings at work and social gatherings with friends." She reports difficulty sleeping, with approximately 4-5 hours of interrupted sleep per night. Patient mentions increased caffeine intake and occasional use of over-the-counter sleep aids.

2. Objective (O)

The objective section contains measurable, observable facts about the patient's condition. Healthcare providers document precise clinical findings such as vital signs, physical examination results, laboratory test outcomes, diagnostic imaging findings, and clinically observable symptoms that can be independently verified.

Example Objective Entry:

Patient appears visibly tense during the session. Affect is anxious, with frequent fidgeting and minimal eye contact. Beck Anxiety Inventory score: 28 (moderate to severe anxiety). Blood pressure slightly elevated at 138/85. No signs of acute medical distress. Breathing appears shallow and rapid at times. Patient demonstrates heightened startle response during discussion of social interactions.

3. Assessment (A)

This section provides a professional interpretation of the patient's condition. Healthcare providers analyze the subjective and objective information to develop a clinical assessment. This includes potential diagnoses, an analysis of test results, an evaluation of the patient's progress, and a comparison with previous medical assessments.

Example Assessment Entry:

Diagnosis of Generalized Anxiety Disorder (GAD) with social anxiety components. Current symptoms indicate moderate to severe anxiety impacting professional and personal functioning. Patient demonstrates typical cognitive and physiological markers of anxiety disorder. Ongoing treatment and cognitive behavioral therapy recommended to address underlying anxiety triggers and develop coping mechanisms.

4. Plan (P)

The plan outlines the proposed treatment strategy and future medical approach. This comprehensive section details recommended treatments, medication prescriptions, necessary diagnostic tests, potential referrals, and specific follow-up instructions tailored to the patient's unique medical needs.

Example Plan Entry:

• Continue weekly cognitive behavioral therapy sessions.

• Prescribe Sertraline 50mg daily, to be monitored and adjusted as needed.

• Introduce mindfulness and relaxation techniques.

• Recommend weekly support group for social anxiety.

• Schedule follow-up in 4 weeks to assess medication response and therapy progress.

• Provide psychoeducation materials on anxiety management.

• Develop collaborative strategy for gradual exposure to social situations.

  
  

How Long is a SOAP Note?

The length of a SOAP note can vary depending on the healthcare setting, complexity of the patient's condition, and specific institutional requirements. 

Typically, a comprehensive SOAP note ranges from half a page to two pages for outpatient visits. More complex cases or initial consultations might require more detailed documentation, potentially extending to three or more pages.

For Mental Health Professionals

Therapists and mental health professionals often create more narrative-rich SOAP notes due to the complex nature of psychological assessment. These notes generally range from one to three pages, depending on the session type and patient complexity.

Typical length breakdown for therapy SOAP notes:

• Initial intake sessions: 2-3 pages

• Standard therapy follow-up: 1-2 pages

• Brief check-in sessions: 0.5-1 page

Factors Influencing SOAP Note Length

Several key factors determine the length of a SOAP note:

• Complexity of the patient's condition

• Type of healthcare encounter (initial visit vs. follow-up)

• Specific documentation requirements of the healthcare institution

• Insurance and billing documentation needs

• Depth of assessment and treatment planning

Electronic health record (EHR) systems have also influenced SOAP note length, often providing structured templates that guide healthcare providers in creating thorough yet efficient documentation. The goal is always to capture essential information succinctly and professionally.

SOAP Notes Best Practices

Healthcare professionals should prioritize specific and concise documentation. It is crucial to maintain objectivity, separating factual observations from personal interpretations. 

Be Chronologically Precise

Always document information in the order of the SOAP framework. Start with the subjective information from the patient, move to objective clinical findings, provide a professional assessment, and conclude with a clear treatment plan. Maintaining this structured approach ensures that anyone reading the note can easily follow the patient's medical journey.

Use Clear and Concise Language

Avoid medical jargon that may confuse other healthcare providers or the patient. Choose words that are specific and descriptive while remaining easily understandable. For example, instead of writing "patient appears uncomfortable," specify the exact nature of discomfort, such as "patient grimaces when attempting to sit and reports sharp lower back pain."

Maintain Objectivity

Separate factual observations from personal interpretations. In the objective section, focus on measurable, observable data. Avoid including personal opinions or speculative statements.

If you must include a professional observation that goes beyond pure measurement, clearly distinguish it as such.

Be Specific and Detailed

Provide enough context to give a complete picture of the patient's condition. Include relevant medical history, current symptoms, physical examination findings, and treatment responses. Specificity helps other healthcare providers understand the patient's condition without requiring additional context.

Common Mistakes to Avoid When Writing SOAP Notes

Practitioners should be cautious about creating vague or incomplete documentation. It is essential to avoid mixing subjective feelings with objective facts and to maintain consistent updates. Using unprofessional or non-standard language can compromise the quality and effectiveness of medical documentation.

Why SOAP Notes Matter

SOAP ensures continuity of care by providing a clear, chronological record of patient interactions.

These notes facilitate communication between healthcare providers, support medical decision-making, serve as legal documentation, and enable effective tracking of patient progress over time.

Bottom Line

Mastering SOAP notes is an essential skill for healthcare professionals across various disciplines. By following a structured approach and maintaining clear, comprehensive documentation, practitioners can significantly enhance patient care and clinical communication.

Disclaimer: SOAP note examples are for educational purposes. Always follow your specific institutional guidelines and professional standards.

Sources

McDonald, C. J. (2019). Remembering Lawrence Weed: A pioneer of the SOAP note. Academic Medicine, 94(1), 11-12.

National Center for Biotechnology Information. (n.d.). Problem-oriented medical record. In StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/