A SOAP note is a documentation format employed by doctors, nurses, behavioural health counsellors and others in the health care industry. SOAP is an acronym for subjective, objective, assessment and plan. Health care providers are encouraged to adhere to this standard to ensure consistent documentation across the industry. When SOAP notes are used, other providers, auditors or accreditation councils can easily review patients’ charts and find the information that is required.
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Things you need
- Patient chart
- Case note form or case note program
Begin the SOAP note using the format desired by the organisation or hospital. Most begin by listing the patient or client's name, case number, date of service and any diagnosis or procedure coding. The remainder of the SOAP note should be broken into four distinct paragraphs or sections.
Write the subjective part of the note. Note observations made about the patient or client from the caregiver's point of view. For example,"The patient looked tired and seemed agitated," would be a subjective remark.
Write the objective part of the note. Objective notations are those that result from viewing the patient or client. They can also address physical measurements, such as body temperatures or flushed skin.
Write an assessment. The assessment is the caregiver's diagnosis of the client or patient's current status. Several diagnoses can be included in the assessment.
Write the plan section of the SOAP note. This will include treatment or medication prescribed, follow-up care and patient or client instructions.
Tips and warnings
- Follow the guidelines provided by regulating authorities when writing SOAP notes.
- If you are unfamiliar with your organisation preferred format, ask a colleague how to write a SOAP note that is consistent with documentation policies.
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