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The Four Parts of a SOAP Note
S - O - A - P
1. SUBJECTIVE
— The initial portion of the SOAP note format consists
of subjective observations. These are symptoms the patient verbally expresses or as stated by a
significant other. These subjective observations include the patient's descriptions of pain or discomfort,
the presence of nausea or dizziness, when the problem first started, and a multitude of other
descriptions of dysfunction, discomfort, or illness the patient describes.
2. OBJECTIVE
— The next part of the format is the objective
observation. These objective observations include symptoms that can actually be measured, seen,
heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature,
pulse, respiration, skin color, swelling and the results of diagnostic tests.
3. ASSESSMENT
— Assessment follows the objective observations.
Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as
a contusion. However, an assessment may not be clear and could include several diagnosis
possibilities.
4. PLAN
— The last part of the SOAP note is the health care provider's plan. The plan may
include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments
performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient
disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work,
admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and follow-up directions
for the patient.
Medical Assistant SOAP NotesExamples are as a medical assistant would enter the patient's demographics, and subjective, and objective segment into a patient's record. The assessment and plan is written by the doctor. The entries are initialed by the medical assistant, while the provider signs them also.
Soap Note Example 1:
Patient Name: Robert Kryle DOB:
12/31/1961
Record No. K-6112r809
Date: 09/09/1999
S—Pt. states that she
has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next
year and she would like to begin working toward a weight loss goal that is realistic. NKDA,
NKA.
O—WT = 210 lbs HT = 60
“ BW = 115 lbs Chol = 255 BP = 120/75
A—Obese at 183% IBW,
hypercholesterolemia
P—Long Term Goal:
Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to
begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and
smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in
one week.
———————————————————————————
Soap Note Example 2:
Patient Name: Lisa Brown DOB: 2/3/1960
Record No. B-583uw809
Date: 10/19/2001
S—Pt. here for weekly
BP check, no complaints. NKDA, NKA.
O—BP 142/88; Atenolol
50 mg daily
A—hypertension
controlled
P—Continue Atenolol;
RTO 6 months
———————————————————————————
Soap Note Example 3:
Patient Name: Lisa Brown DOB: 2/3/1958
Record No. B-583uw809
Date: 04/21/2005
S—Pt. here for 6 mos.
follow-up visit, no complaints. NKDA, allergic to latex
O—BP 142/88; Atenolol
50 mg daily
A—hypertension
controlled
P—Continue Atenolol;
RTO 6 months
———————————————————————————
Soap Note Example 4:
Patient Name: Robert Dreg DOB: 09/17/1967
Record No. D-679dk978
Date: 12/4/2007
S—Pain in left hip x 3
months; worse when walking or doing exercise. NKDA.
O—Wt. 195 lb, Ht.
5'5'', normal ROM both hips, no swelling or redness.
A—Possible
osteoarthritis; R/O rheumatoid arthritis
P—blood work—sed rate,
rheumatoid factor, x ray L hip PA and lateral; ibuprofen 600 mg t.i.d po; recheck 2
months.
———————————————————————————
Soap Note Example 5:
Patient Name: Paul Kessler DOB:
11/03/1961
Record No. K-470pk624
Date: 21/8/2008
S—Mild burning with
frequent urination, a thin discharge that is worse in the A.M., irritation at the urinary opening at tip
of penis, NKA.
O—Discharge with gram
stain negative for gonorrhea, showing large numbers of WBCs. Chlamydia test is
positive.
A—Non-Gonorrheal
Urethritis
P—Doxycycline 100mg BID
for 10 days or Erythromycin 500mg QID for 10 days or Tetracycline 500mg QID for 10 days. Increase fluid
intake, avoid alcoholic beverages. Pt education on safe sex practices.
———————————————————————————
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