Clinicals
SOAP Note Guide
Apr 12, 202612 min read
By Mike
By MikeThe SOAP note is the backbone of clinical documentation. You'll write hundreds of them during clerkships and thousands more in residency, so learning to write them well early on will save you time, earn you credibility with your team, and, most importantly, help you take better care of your patients. This guide breaks down each section, walks through a sample note, and covers the mistakes students make most often.
SOAP stands for Subjective, Objective, Assessment, and Plan. It's a structured format for organizing your clinical thinking every time you see a patient. Each section has a specific purpose, and keeping information in the right section makes your notes clear, useful, and easy for other providers to follow.
Think of it this way: the SOAP note is how you communicate your clinical reasoning to everyone else on the care team (and also serves as a legal document and billing document). A well-written note tells the reader what the patient is experiencing, what you found on exam and in the data, what you think is going on, and what you're going to do about it.
This is the patient's story in their own words. What are they telling you? How are they feeling? The subjective section captures the information you gather by talking to and listening to your patient.
What belongs here:
Tips:
This is everything you can measure, observe, or verify independently. If the subjective is what the patient tells you, the objective is what you find.
What belongs here:
Tips:
This is the most important part of your note. The assessment is where you show your clinical reasoning. It answers the question: What do you think is going on, and why?
What belongs here:
Tips:
The plan is what you're going to do about each problem. It should flow directly from your assessment and be specific enough that another provider could pick up where you left off. Much of this is often templated or in selectable fields for an inpatient note.
What belongs here:
Tips:
Here's an example of a concise admission note for an internal medicine patient presenting 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:
Imaging:
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:
Code status: Full.
If you find yourself writing "the patient appears to have pneumonia" in the objective section, that's an assessment. The objective should contain findings, not interpretations. Save your clinical reasoning for the A section.
Electronic medical records make it easy to copy yesterday's note and tweak a few things. However, if you are not careful, then this will add to "note bloat" and give outdated information to team members reading your note. Outdated exam findings, old lab values, and stale assessments erode trust in your documentation and can lead to errors. Write each note fresh, or at minimum, update every section deliberately.
A note that only lists what the patient does have misses half the picture. Documenting what you ruled out and why shows stronger clinical thinking and helps the next provider understand your reasoning.
If your plan says "order CT abdomen" but your assessment doesn't explain why you're concerned about an intra-abdominal process, the note feels disconnected. The assessment and plan should read as a cohesive argument.
More words do not equal a better note. Attendings and consultants are reading dozens of notes a day. Respect their time by being thorough but efficient. Include what matters and leave out what doesn't. Your cross cover and night team will also thank you.
| Section | Key Question | Content |
|---|---|---|
| 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 |
The SOAP note is the primary clinical/legal/billing documentation that you will construct. Writing a good note forces you to organize your thoughts, justify your decisions, and communicate clearly with your team. Early in clerkships, your notes will take a long time to write and that's completely normal. With practice, you'll get faster without sacrificing quality.
One last piece of advice: read other people's notes. Find an attending or senior resident whose documentation you admire and study how they structure their thinking. You'll pick up patterns and phrasing that you can adapt to your own style. Also take their smart phrases or note templates to standardize and expedite the note writing process!
Best of luck!
— Mike