The SOAP method is a structured approach to clinical documentation used by healthcare providers to organize patient information in a standardized, readable format. This system ensures that all relevant details from a patient encounter are captured systematically within the medical record. Developed by Dr. Lawrence Weed nearly 50 years ago, the format originated from the problem-oriented medical record. The purpose of this methodology is to create an organized record of a patient’s health status, clinical reasoning, and treatment decisions. Today, the SOAP note is widely adopted across various medical disciplines and is often integrated into modern electronic health record (EHR) systems.
Understanding the Four Components
The SOAP acronym represents four distinct sections: Subjective (S), Objective (O), Assessment (A), and Plan (P). This structure guides the clinician through a logical sequence, starting with the patient’s perspective and concluding with the strategy for future care. Separating information into these categories provides a clear framework for clinical reasoning, which involves evaluating the data to form a diagnosis and treatment path.
Subjective (S)
The Subjective section documents the patient’s personal experience, symptoms, and concerns as reported by the patient or a representative. This includes information that cannot be measured or verified by the clinician, such as the patient’s chief complaint, often recorded in the patient’s own words. Relevant medical history, including current and prior diagnoses, medications, and allergies, is also documented here. Clinicians may use acronyms like OLDCARTS to ensure a thorough history of the present illness is captured.
Objective (O)
The Objective section is strictly for measurable, observable, and verifiable data collected by the healthcare provider. This section includes the patient’s vital signs (heart rate, blood pressure, respiratory rate, and temperature). Results from diagnostic testing, such as laboratory values, imaging reports, and electrocardiograms, are recorded here. Findings from the physical examination, including specific measurements and descriptions, are also documented to provide factual evidence supporting the encounter.
Assessment (A)
The Assessment section represents the clinician’s professional summary and interpretation of the Subjective and Objective data. This is where the synthesis of collected information occurs to formulate a clinical judgment or diagnosis. For new patients, this section may include a list of differential diagnoses, which are the possible conditions considered. For established patients, the Assessment details the patient’s progress or regression since the previous visit and the status of existing problems.
Plan (P)
The Plan section outlines the course of action for managing the patient’s condition and addressing each problem identified in the Assessment. This includes details about any diagnostic tests ordered (such as blood work or X-rays) and any prescribed medications, including dosage and frequency. Therapies, procedures, referrals to specialists, and patient education provided during the visit are also documented here. The Plan specifies the follow-up instructions and the goals of treatment.
How SOAP Notes Improve Patient Care
The structured nature of SOAP notes provides a consistent methodology that enhances the quality and reliability of healthcare delivery. Clear records allow care teams to quickly understand a patient’s condition, the interventions attempted, and the future management strategy. This clarity promotes coordination across different providers, which is beneficial in complex or urgent situations where timely, well-informed decisions are necessary.
The standardized format facilitates the seamless transfer of information between clinicians, ensuring continuity of care even when a patient is seen by multiple specialists. When notes follow the same logical organization, any provider can rapidly access the patient’s story, findings, and treatment plan. This consistency reduces the risk of miscommunication and helps to track a patient’s progress accurately over time.
Documentation in this format also serves as a strong legal document of the patient encounter and the provider’s clinical reasoning. Well-written notes provide a safeguard in case of audits, billing checks, or legal disputes by clearly outlining the care provided. These records are frequently used to justify the medical necessity of services to insurance companies.
Contexts Where the SOAP Method is Used
The SOAP format has been adopted widely beyond its original use in general medicine due to its clear structure. Professionals across numerous health disciplines rely on this method to document patient interactions effectively. This standardized documentation is common in fields such as physical therapy, occupational therapy, and speech-language pathology, where therapists track specific functional goals and measurable progress.
Nurses and prehospital care providers, like emergency medical technicians, also utilize this format to communicate patient information efficiently. In mental health and counseling settings, the format is used to document therapy sessions, often focusing on behavioral observations and psychological status. Chiropractors rely on SOAP notes to document the patient’s response to adjustments and to support the medical necessity of their services. The consistent structure has made it the default standard for documentation in most healthcare settings.