What are SOAP Notes? The Science of Medical Documentation

Let's talk about every clinician's favorite acronym (and no, I don't mean WNL).

SOAP (Subjective, Objective, Assessment, Plan) notes are a universal method of clinical documentation. The classic format helps guide conversations while prioritizing the information that matters most.

But the SOAP methodology is so much more than a way to write medical notes. It's a cognitive framework that helps clinicians keep an open mind while tackling problems head on.

Let's dig into SOAP's fascinating history, and the role it plays in patient care.

What are SOAP notes?

Getting the definition out of the way: SOAP notes—short for Subjective, Objective, Assessment, and Plan—are a standardized way to record patient encounters.

But it's actually a branch of a larger concept: "the problem-oriented medical record" or "PoMR."

While that's a way less catchy abbreviation, it gets to the bottom of the SOAP methodology: which is to focus on what's there, not just the interpretation of it.

The history of SOAP notes

SOAP's pioneer, Larry Weed, was both a practicing physician and research scientist. With a foot in both worlds, he realized that medicine could learn a thing or two from the problem-centric approach to scientific study.

But of course, clinicians aren't scientists, and their work isn't one and the same. In Weed's words:

"A physician works in a chaotic system of keeping and organizing data and has no systematic review and correction of his daily work."

So he set out to create a process for gathering patient information that imbued a much-needed structure into how we write progress notes.

The problem list

According to Loyola University, the problem list is the first step of what clinician's "really do." That is, to determine "what is wrong with the patient."

This can start with a list of abnormalities so that you can find patterns and a possible explanation of the problem.

There's no "wrong" way to do this. Loyola's example is if a beginning medicine clerk listed six problems (like abdominal pain, vomiting, etc.)  that all add up to one problem: uremia.

While a second-year student could call it uremia at the jump, what really matters is that we have the information we need to identify the problem.

With this in mind, SOAP's approach to medical documentation aims to capture and address the problems what we directly observe and discuss.

SOAP note format

Now, let's put Weed's format into action. A SOAP note document breaks down critical information into a(n):

Subjective: The patient's perspective, subjective complaints and concerns.

Let's start with the chief complaint: why did the patient schedule the appointment?

This leads to the narrative and symptoms for the present illness.

The Subjective section also incorporates the patient’s personal history: our trusty Problem list, medication list, medication allergy, social history, family history, etc.

Patient information:

• Name, date of birth, date of encounter

Chief complaint:

• Why the health professional is seeing the patient for the appointment

Subjective:

• History of present illness, current signs and symptoms
• Past medical history
• Past surgical history
• Medication list
• Medication allergy list
• Social history
• Family history

Objective: Objective findings from observable data, like the physical exam, vital signs, and diagnostic tests. Basically, the Objective section will address the data that the clinician is discerning and analyzing.

• Physical exam
• Vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, pain level, and height/weight)
• Diagnostic tests (labs, radiology images, electrocardiogram, etc.)

Assessment: Sums up the patient's perspective and your observations in the problem and any differential diagnosis.

The Assessment section includes the clinician’s interpretation of the signs and symptoms, objective data, clinical reasoning, and medical diagnoses.

• Differential diagnoses
• Medical diagnoses
• Clinical reasoning

Plan: Here's what's next in your treatment plan: immediate action, diagnostic tests, and follow-up appointment. The Plan section is specific to the patient and diagnoses.

• Plan of care
• Prescriptions, over-the-counter medications
• Referral to speciality
• Follow-up
• Education

Not only does this medical information keep things organized— it's vital for continuation of care. You're playing an active role as the "scribe" (for lack of a better word) in a patient's medical history. How can you best represent your patient's care for future physicians?

How to write SOAP notes effectively

Here's what Weed himself looks for in a medical note:

"Are practitioners thorough? Are they reliable? Are they analytically sound? And are they efficient?"

Don't worry, he's not advocating for note bloat here. What he means is, do you have the data that you need to provide care in a reasonable amount of time?  

This might feel easier said than done. Here are some tips to help get the medical information you need in a chart, without having to work off hours to do it.

1. Start with a Template

Now that we have the SOAP format down, how can we templatize our notes even more?

Many electronic health record (EHR) systems offer customizable templates to help clinicians write progress notes. Tailor one to your practice, pulling information based on the common conditions you treat.

• Pro tip: Include pre-written text for common symptoms and findings to reduce repetitive typing. Also take advantage of smart/dot phrases to reduce time charting.

2. Stay Focused and Concise

Clarity is king; and brevity is your new best friend.

A thorough medical note doesn't need to be overblown.

Some clinicians avoid paragraphs altogether in their progress notes. For example, instead of writing a lengthy narrative in paragraph format, summarize key points.

• Example: Replace "The patient said they started having mild chest discomfort three days ago and it has gradually worsened, especially with exertion" with "Chest discomfort x3 days, worsening with exertion."

3. Listen Actively During the Subjective

The subjective section of the visit is where patients share critical information.

But if we ask open-ended questions, they can easily go off-topic (and quickly off the reals) to describe something that's actually not relevant.  Focus on direct questions to gather the history of present illness.

• Helpful prompt: “When did your symptoms start? What makes it worse? What makes it better?”

4. Organize the Objective Section Logically

List objective findings in a systematic order (e.g., physical exam by system, vital signs, and diagnostic data). This makes your notes easier to follow. The health professional can also explain a test result in the Objective section.

• Tip: Use shorthand or abbreviations for commonly recorded items, such as “WNL” for "within normal limits."

5. Craft a Thoughtful Assessment

This section is where your expertise and cognitive framework shines. Prioritize the most likely diagnosis first, but also explain relevant differentials. Keep the language clear for your colleagues and future self.

Example:

• Primary diagnosis: Acute bronchitis.
• Differential: Pneumonia vs. asthma exacerbation.

6. Make the Plan Actionable and Specific

Your plan should leave no room for ambiguity. Include medications, dosages, lifestyle recommendations, and clear instructions for follow-ups.

Example:

• Start azithromycin 250 mg daily for 5 days.
• Increase fluids and rest.
• Return if symptoms worsen or fail to improve in 48 hours.

In some instances, the assessment and plan may be combined for greater note efficiency.

7. Use EHR Efficiency Tools

Leverage tools like voice-to-text dictation, smart phrases, and auto-populated fields in your EHR to speed up the process. I have a whole list of smart/dot phrases that help me save time charting instead of redundantly typing out the same phrases. Check out my list of smart phrases here!

• Pro tip: Create a library of smart phrases for common diagnoses and treatments (e.g., "URI plan," "HTN management").

8. Avoid Copy-Paste Pitfalls

Copying previous notes can save time but risks errors. Always review and tailor copied information to the current visit.

• Example: If you copy a "normal" physical exam, ensure it reflects any new findings or changes.

9. Use AI Medical Scribes

Artificial intelligence (AI) tools are a great way to save time here. AI medical transcription tools or AI scribes can write notes while you make observations.

10. Reflect on Your Process

Evaluate what’s working and where you can improve. Consider tracking how long it takes to complete notes and identifying bottlenecks.

Conclusion

At the end of the day, SOAP can help you get what you need to provide the best possible patient care.

As Weed himself said "We’re really not taking care of records; we’re taking care of people. . . . This record cannot be separated from the caring of that patient. . . . This is the practice of medicine.”

By combining the science with person-centered practices, we can prioritize what matters most, real people working together to solve problems.

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Freed is an AI scribe that listens, transcribes, and writes SOAP notes. Try it for free.