Writing a SOAP Note

Medical offices, clinics, and hospitals need medical assistants MORE than EVER! Join the "Community of Caring" by starting a rewarding career as a medical assistant! We provide important resources, such as career and self-study guides, certification and scope-of-practice info, active message boards, schools, and job listings in every state to help you get started.

Follow your heart... be a medical assistant!

Explore Hundreds of Medical Assistant Schools Near You!

Click button below

Select your state

View all schools---It's that simple!

	Writing a SOAP Note

	Move Your Career In The Right Direction!
	Do You Want Your Career To Stand Out or Stand Still? Sadly, many medical assistants have told us that not having sought certification sooner was a mistake they came to regret. Until they took charge their career went nowhere... but precious time was lost. We don't want this to happen to you! Take the first step in the right direction today. Receive this FREE Career Information Kit IT'S IMPORTANT - And 100% FREE!

Writing a SOAP Note:

The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN (SOAP Note Examples). The SOAP note is written to improve communication among all those caring for the patient to display the assessment, problems and plans in an organized format. Writing SOAP notes facilitates better care of the patient when used in the patient's record for review and quality control.

In most cases, SOAP notes are written by the physician and other licensed healthcare providers, such as the physician's assistant (PA), or licensed nurse practitioner. However, with correct training and proper supervision a medical assistant is also allowed to briefly interview the patient and enter the patient's reason for the visit under the "Subjective" line (S) into the SOAP note.

As the medical assistant takes the patient's vital signs, height, and weight measurements this can be entered into the medical record under the "Objective" area (O) to be reviewed minutes later by the physician.

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 "O" part of the SOAP note.

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.

The SOAP note is not supposed to be as detailed as a progress report. Complete sentences are not necessary and abbreviations are appropriate. However, avoid them until you have a handle on how the abbreviations are used—they differ for each specialty and are consistent within the medical office where you work.

The length of the note will differ for each specialty as well. SOAP notes can be flexible. You will develop your own style as you try to accommodate office preferences. The note written by a novice will usually turn out to be a little longer than that of the more advanced staff with more clinical judgment and experience in proper SOAP note writing format. It is practice that makes perfect.

The inexperienced writer will often give more thought as to what to write and usually will wind up putting more of what they have observed to paper than necessary. A short, but precise SOAP note is often better than an entry that is too verbose. As medical assistants experiment and become more proficient, they eventually develop their preferred technique to remain short and accurate.

Medical documentation of patient complaint(s) and treatment must be consistent, concise and comprehensive. Many medical offices use the SOAP note format to standardize medical evaluation entries made in clinical records.

Don't Mistake a SOAP Note for a Progress Note!

As the name implies, a progress note sums up the progress that has been made in the patient’s care since the last note. SOAP stands for subjective, objective, assessment and plan. The SOAP note is a brief report in the patient's chart, done at the day of the appointment when the patient is seen. It is different from the comprehensive progress note the doctor writes in the physical diagnosis.

What Information to Include:

The instructions below should give you a general idea of what information to include and where. Many of the particulars of your notes will be different for each medical specialty, so be sure to get feedback from your medical office manager and coworkers about your notes as early as possible and adjust your style accordingly.

Attention:

FREE--Just For the Asking

Career Information Kit & Study Guide...

Click for details how to get
this free career information!

The SOAP Note should briefly express the following:

Date and purpose of the visit. The patient’s symptoms and complaints

The current physical exam. What is the patient's height, weight, temperature, pulse, blood pressure, visual acuity, etc.

New lab data and results of studies, reports, assessments

The current formulation and plan for the patient

Always remember that the patient's medical record is a LEGAL document!!! So do it right.

Therefore, be bold in your presentations, but conservative when charting. Also, because the patient's medical record is a legal document, you should start your note right after the last note in the chart so it will always be in chronological sequence.

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.

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.

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.

Always 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 medicolegal purposes and so others can contact you with questions about what you have written.

See SOAP Note Examples!