SOAP Note Examples for Medical Assistants

A SOAP note is always written in a particular format; its purpose is to record information regarding a specific patient's treatment in a consistent manner. The SOAP note format continues to be the format of choice in ambulatory medical settings.

Parts of the SOAP Note

The medical assistant is allowed to write the "S" part into the patient's record exactly as stated by the patient and is allowed to write the "O" part into the patient's record exactly as observed. The medical assistant is not allowed to write the "A" part into the patient's record and not allowed to write the "P" part into the patient's record. 

 SUBJECTIVE — The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by an accompanying relative or 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.

 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. 

 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.

 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.

Using Abbreviations in a SOAP Note

SOAP Note Abbreviations Key  CC = Chief Complaint WT = weight HT = height  IBW = ideal body weight  BP = blood pressure  Chol = cholesterol  Pt = patient  RTO = Return to office  ROM = range of motion  R/O = rule out  PA= posterior/anterior  P = pulse T or temp = temperature

NKDA = No known drug allergies NKA = No known allergies BS = blood sugar  UA = urinalysis  VA = vision acuity  O.S. = left eye  O.D. = right eye  O.U. = both eyes

SOAP note examples given below are as a medical assistant would typically enter the patient's demographics, subjective and objective segment into a patient's record. The assessment and plan is written by the doctor and NEVER by the medical assistant. The medical assistant's entries are initialed by the medical assistant, while the provider checks, verifies and signs them also. Ultimately it is the doctor/provider's responsibility to ensure that all content of the SOAP note is written properly, and accurately reflects the statements, conditions, findings and services as provided.

Example SOAP Note 1:

SOAP Note Example 2:

SOAP Note Example 3:

SOAP Note Example 4:

SOAP Note Example 5:

CONTINUE What is a SOAP Note?

CONTINUE Writing the SOAP Note