Writing a SOAP Note

You'll write hundreds of SOAP notes in clerkships and thousands more in residency. Getting good at them early saves you time, earns you some credibility with your team, and makes you a better doctor for your patients. Below I go through each section, then a full sample note, then the mistakes I see students make most.

What a SOAP note is

SOAP stands for Subjective, Objective, Assessment, and Plan. It's a fixed order for your thinking every time you see a patient. Each section has one job, and keeping things in the right section is what makes a note easy for the next person to follow.

The note is how you tell the rest of the care team what you think (it's also a legal document and a billing document). A good one tells the reader what the patient is going through, what you found on exam and in the data, what you think is going on, and what you're going to do about it.

S: Subjective

The patient's story, in their words. What are they telling you, and how do they feel? This is everything you learn by talking to them and listening.

What goes here:

• Chief complaint (CC): why they're here, or the main issue today. Abdominal pain, rash, headache. Keep it short.
• History of present illness (HPI): the narrative. Cover onset, location, duration, character, aggravating and alleviating factors, radiation, timing, and severity (OLDCARTS, if you learned it that way), in an order that makes sense.
• Review of systems (ROS): a pass through the organ systems. Document the pertinent positives and negatives for your differential. Common ones are fever, chills, night sweats, abdominal pain, and so on.
• Interval updates: on inpatient notes, how the night went, anything new, changes in pain, whether they're eating and walking, and any worries they have.

Lead with what matters most. Don't make the reader get three sentences in before they learn why the patient is here.

Be short but complete. You don't need every word the patient said, just the details that matter clinically.

Pertinent negatives count. If chest pain is on your differential, writing that they deny shortness of breath, nausea, and diaphoresis matters as much as what they do report.

O: Objective

Everything you can measure, see, or check yourself. If subjective is what the patient tells you, objective is what you find.

What goes here:

• Vitals: temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Include trends or ranges when they matter, like being afebrile for 48 hours after a fever on admission. Your template will often pull these in for you.
• Physical exam: findings by system, and be specific. "Lungs clear to auscultation bilaterally" beats "lungs normal." "Abdomen soft, non-tender, non-distended with normoactive bowel sounds" beats "abdomen benign."
• Labs: the relevant ones, especially new results and trends. You don't need every value from the whole admission, only what matters today.
• Imaging and studies: a summary of relevant imaging, EKGs, pathology, and other tests.
• Medications: some settings put the current med list here. At least note any changes.
• Ins and outs: on inpatient notes, include fluid balance when it matters, like in heart failure or AKI.

Only write down what you actually examined. Don't document a cranial nerve exam you didn't do.

Format it the same way every time so your team can scan it.

For trends, "Cr 1.2 (down from 1.8 on admission)" says more than today's number alone.

A: Assessment

This is the most important part of the note. It's where your reasoning shows. It answers one question: what do you think is going on, and why?

What goes here:

• A one-liner. For example: "This is a 72-year-old male with history of CHF and CKD presenting with three days of worsening dyspnea, likely secondary to acute decompensated heart failure now improving with diuresis."
• A problem-based assessment. For each active problem, give your working diagnosis or differential and your reasoning. Tie the subjective and objective data together.
• Why you lean the way you do. For each problem, say briefly why you favor your leading diagnosis and what else you're thinking about.

This is where students struggle most, and it's also where you can impress your team most. Don't restate the facts. Explain your thinking, the way your math teacher made you show your work.

Your assessment should make the plan feel obvious. If someone reads it and is surprised by the plan, something's missing.

P: Plan

What you're going to do about each problem. It should follow straight from the assessment and be specific enough that someone else could pick it up. On inpatient notes a lot of this is templated or in selectable fields.

What goes here:

• A plan for each problem: the tests you're ordering, meds you're starting, stopping, or changing, consults, and monitoring.
• Disposition: going home, staying another day, and what has to happen before discharge.
• Education and counseling.
• Follow-up: when, and with whom.

Be specific. "Continue current management" tells the reader nothing. "Continue IV furosemide 40mg BID, monitor daily weights and I/Os, recheck BMP in the morning" tells them everything.

Match the plan to the assessment. If the assessment has three problems, the plan covers all three in the same order.

Think about what happens if it doesn't work. Saying what you'll do if the patient doesn't improve shows you're thinking ahead.

A sample note

Here's a concise admission note for a medicine patient with a COPD exacerbation.

S:

Mr. Johnson is a 68-year-old male with PMH of COPD (on 2L home O2, FEV1 42% predicted on last PFTs 6 months ago), HTN, T2DM, HFrEF (EF 35%), and 40 pack-year smoking history (quit 2 years ago) who presents to the ED with 3 days of worsening dyspnea, increased cough, and increased purulent sputum production. He reports his symptoms started after his grandchildren visited and several had URIs. He has been using his albuterol inhaler every 2 to 3 hours with minimal relief (baseline use 2 to 3 times per week). He denies fever, chest pain, hemoptysis, leg swelling, or orthopnea. He reports compliance with his home medications including tiotropium, fluticasone/salmeterol, and lisinopril. He denies recent medication changes or missed doses. He has had two prior COPD exacerbations requiring hospitalization in the past year, most recently 4 months ago. No prior intubations. He denies recent travel, sick contacts other than grandchildren, or known COVID-19 exposure. ROS positive for fatigue and decreased appetite over the past 2 days. ROS negative for fevers, chills, chest pain, palpitations, LE edema, abdominal pain, N/V, dysuria.

O:

• Vitals: T 99.1, HR 102, BP 148/82, RR 24, SpO2 88% on 4L NC (baseline 2L), BMI 26
• General: Alert, oriented, speaking in short sentences, using accessory muscles, appears mildly distressed
• HEENT: MMM, no JVD
• Lungs: Diffuse bilateral expiratory wheezing, prolonged expiratory phase, decreased breath sounds at bases bilaterally, no crackles
• CV: Tachycardic, RRR, no murmurs/rubs/gallops, no peripheral edema
• Abdomen: Soft, NT/ND, +BS
• Extremities: No cyanosis, no clubbing, no edema
• Neuro: A&Ox3, no focal deficits

Labs:

• CBC: WBC 11.8 (no left shift), Hgb 14.2, Plt 210
• BMP: Na 138, K 4.1, Cl 98, CO2 32 (baseline 30), BUN 18, Cr 1.0, Glu 182
• ABG (on 4L NC): pH 7.35, pCO2 52 (baseline 46), pO2 62, HCO3 28
• ProBNP: 450 (baseline 300 per last admission)
• Procalcitonin: 0.15
• Troponin: <0.01
• Influenza/COVID: Pending
• Blood cultures x2: Pending
• Sputum culture: Sent

Imaging:

• CXR (PA/lateral): Hyperinflated lung fields, flattened diaphragms, no focal consolidation, no pleural effusion, no pneumothorax. Stable cardiomegaly.
• EKG: Sinus tachycardia at 102, RAD, low voltage, no acute ST-T wave changes, unchanged from prior

Home medications: Tiotropium 18mcg INH daily, fluticasone/salmeterol 250/50 INH BID, albuterol PRN, lisinopril 20mg daily, metformin 1000mg BID, atorvastatin 40mg daily, aspirin 81mg daily

A:

Mr. Johnson is a 68-year-old male with COPD (GOLD stage III), HFrEF, HTN, and T2DM presenting with an acute exacerbation of COPD, likely triggered by a viral URI. His ABG is consistent with a mild acute-on-chronic respiratory acidosis with compensated metabolic alkalosis consistent with his baseline CO2 retention. CXR does not show consolidation to suggest PNA. Procalcitonin is low, which argues against bacterial pneumonia. ProBNP is mildly elevated above baseline but clinical picture is more consistent with COPD exacerbation than acute decompensated HF given absence of edema, orthopnea, and pulmonary congestion on CXR. This is his third exacerbation in 12 months, which qualifies as frequent exacerbator phenotype and will need to be addressed at follow-up.

P:

1. Acute COPD exacerbation: Duonebs (albuterol/ipratropium) q4h and PRN. Prednisone 40mg PO daily x 5 days. Continue home tiotropium and fluticasone/salmeterol. Azithromycin 500mg PO daily x 3 days given purulent sputum and severity. Monitor ABGs in the AM and if developing confusion. Respiratory therapy consult for inhaler technique assessment and pulmonary hygiene, appreciate recommendations and comanagement.
2. Acute on chronic hypoxemic/hypercapnic respiratory failure: Maintain SpO2 88 to 92% given chronic COPD. Currently on 4L NC. If worsening hypercapnia or respiratory distress, consider BiPAP. Low threshold for IMC transfer if clinical deterioration. Continuous pulse ox monitoring.
3. HFrEF: Clinically euvolemic on exam. ProBNP mildly above baseline but no signs of acute decompensation. Hold PTA lisinopril. Monitor daily weights and strict I/Os. Limit IV fluids.
4. T2DM: Hold PTA metformin. LDSSI. Fingerstick glucose QAC and QHS. Monitor for steroid-induced hyperglycemia given prednisone course.
5. HTN: Hold PTA lisinopril.
6. DVT prophylaxis: SQ heparin q8h.
7. Disposition: Admit to medicine floor with telemetry. Smoking cessation counseling (reinforce continued abstinence). PCP follow-up within 1 week of discharge. Pulmonology follow-up within 4 weeks to discuss management and possible escalation of maintenance therapy.

Code status: Full.

Common mistakes

Assessment in the wrong section

If you catch yourself writing "the patient appears to have pneumonia" under objective, that's assessment. Objective holds findings, not interpretations. Keep the reasoning for A.

Copying forward without updating

Probably my biggest pet peeve. The EMR makes it easy to copy yesterday's note and change a few things, and if you aren't careful you end up with note bloat and old information in front of your team. Stale exam findings, old labs, and outdated assessments make people stop trusting your notes, and they cause mistakes. Write each note fresh, or at least go through and update every section on purpose.

Leaving out pertinent negatives

A note that only lists what the patient has tells half the story. Writing down what you ruled out, and why, shows your thinking and helps the next person follow it.

A plan with no reasoning behind it

If the plan says "CT abdomen" and the assessment never mentions a worry about something in the abdomen, the note falls apart. The assessment and plan should read as one argument.

Writing too much

Longer isn't better. Attendings and consultants read dozens of notes a day. Be thorough and efficient, and leave out what doesn't matter. Cross-cover and the night team will thank you.

What goes where

Section	The question	What's in it
Subjective	What does the patient tell you?	CC, HPI, ROS, overnight events, patient concerns
Objective	What did you find?	Vitals, physical exam, labs, imaging, medications
Assessment	What do you think is going on?	Summary, problem list, differential, clinical reasoning
Plan	What are you going to do?	Diagnostics, treatments, consults, disposition, follow-up

Last thing

Writing a good note makes you organize your thoughts, defend your decisions, and say it clearly. Early in clerkships each note will take you a long time, and that's normal. You get faster with practice without getting sloppier.

Read other people's notes. Find an attending or senior whose notes you like and look at how they lay out their thinking. You'll pick up structure and phrasing you can make your own. And ask for their smart phrases and templates. It makes writing notes a lot faster.

Best of luck!

Mike