template object header
Medical Assistant Schools
This is the quickest way to explore medical assistant training programs! Enter ZIP code to see matching schools near you.
Zip Code: 
Career:
Degree:
Type:  Online Campus Both     
template object footertemplate object footer
Home | Jobs | Disclosures | Privacy Policy | Terms of Use | Copyrights | Contact Us |
2002 - 2017 Medical Assistant Net
Created by Danni R.
male medical assistant
what you should earn
Medical Assistant NET facebook page
Medical Assistant Net
Find healthcare and medical assistant schools by ZIP Code
CLICK HERE

Writing of the SOAP Note


The reason for the visit is entered into the fist part, the "Subjective" (S) part of the SOAP note
exactly as the patient stated, e.g. if the patient states: "I've had several bouts of dizzy spells over the past 2 days" it's best the medical assistant enters: Patient complains of several bouts of dizzy spells for past 2 days".
The medical assistant may also ask about medications taken and whether the patient has any known allergies to environmental substances, food, or medicines. The patient's response is also listed carefully and accurately under the "S" part of the SOAP note. As the medical assistant takes the patient's vital signs, height, and weight measurements it can be entered into the medical record under the "Objective" (O) part to be reviewed and verified minutes later by the physician.  

Timing: You should start your entry into the medical record right after the last note in the chart so it will always be in chronological sequence, and remember, the patient's medical record is a legal document. Therefore, is okay to be bold in your presentations, but conservative when charting.

Fluency: Write fluently and legibly and do not leave blank lines in between the text. This is to prevent someone else from writing additional information or comments into your original note. If you made a mistake, simply cross out the unwanted part of the sentence, whether its just one word or several sentences, with a single horizontal line. Then write “error” next to or above the corrected area and initial it.

Corrections: Never scribble over any part of the note, or use "white-out" to cover a mistake. Those who read and examine a medical record must be able to see mistakes and know who is responsible for crossing a word or sentences out.

Alignment: For neatness' sake you may want to start at the top of a page and avoid too much (any) blank space above your note. You should also provide room for the doctor, to amend and initial your note at the end.

When a patient arrives at the medical office for an examination there are different levels of services based on four types of examination:

  1. Problem Focused – a limited examination of the affected body area or organ system
  2. Expanded Problem Focused – a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
  3. Detailed – an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
  4. Comprehensive – a general multi-system examination or complete examination of a single organ system (and other symptomatic or related body area(s) or organ system(s)

Source: 1997 Documentation Guidelines for Evaluation and Management Services.

SOAP Note Writing Step by Step

SOAP notes are entered into the patient's medical record during the course of a medical appointment, routine
physical, or medical examination by the doctor, other licensed health care providers and medical assistants.
This entry serves as a permanent record of a patient's condition and treatment for future reference. With
correct training and proper supervision a medical assistant is allowed to briefly interview the patient before the
doctor enters the examination room and enter the patient's reason for the visit under the "Subjective" line of the
SOAP note (the "S-part") along with other important information such as allergies, vital signs and current meds
(in the "O-part"), however a medical assistant NEVER writes the "Assessment" (A) or the "Plan" (P) in a SOAP
note, but should be able to understand this vital part of the medical record entry when reviewing the patient's
chart. Doing so clearly falls outside the medical assistant's limits.
SOAP Note Examples
SOAP note example SOAP note example
Hover over image to see SOAP Note:
Signing the SOAP Note
Last but not least: always initial, or sign your notes after your printed name and include your professional title or credentials. Once again, always leave room on the same page for your notes to be amended and cosigned by the physician under whose supervision you are working. This is important for both medico-legal purposes and so others can contact you with questions about what you have written.

REMEMBER: The medical assistant NEVER writes the "Assessment" (A) or the "Plan" (P) in a SOAP note, but should be able to understand this vital part of the medical record entry when reviewing the patient's chart.