Writing the SOAP Note

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, medical assistant and other licensed healthcare providers. This entry serves as a permanent record of a patient's condition and treatment for future reference.

How Is The SOAP Note Written?

With correct training and proper supervision a medical assistant is allowed to briefly interview the patient before the doctor enters the examination room and note the patient's reason for the visit under the "Subjective" line of the SOAP note, as well as other important information, such as vital signs and current meds.

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 reason for the visit is entered into the "Subjective" (S) of the SOAP note exactly as the patient stated, e.g. "I've had several bouts of dizzy-spells over the 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" area (O) to be reviewed minutes later by the physician.  

SOAP Note Writing Tips:

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.

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:

1. It is okay to be bold in your presentations, but conservative when charting.
   
2. 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.
   
3. 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.
   
4. 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.

CONTINUE  Soap Note Examples

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.

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CONTINUE  Soap Note Review