How to Write a SOAP Note with Examples

We know that SOAP notes can be intimidating at first, but do they really have to be? If you have ever sat in front of a computer screen with a blank stare, wondering how to organize your patient's medical record, you are not alone. A well-organized note ensures clarity to other healthcare providers, makes it easier to track progress, and doesn't let anything important slip through the cracks. Once you get the hang of it and learn how to write SOAP notes, it will become second nature. Let our nursing essay writing professionals break it down step by step.

Steps to follow

• Subjective Section
• Objective Section
• Assessment Section
• Treatment Plan

Good notes keep you and your staff's life easier. It also helps your patients get better care. This article will help you learn how to write these notes and also provide a SOAP note example. From progress notes to research papers to learning how to write case notes that are easily understandable, we can help you stay on track with EssayPro’s nursing assignment writing help.

What is a SOAP Note?

To write a SOAP note means to track the progress of a patient. It helps healthcare providers to keep everything in line. We don't want anything to get left behind. It consists of four main sections: Subjective, Objective, Assessment, and Plan. Each one of them has a particular function. This method helps other healthcare professionals to fully understand the patient's condition. Good documentation means better care and no room for errors. As we said, with time, the SOAP format becomes second nature.

How Long Should a SOAP Note Be?

This document should be brief and to the point - usually two to four paragraphs. The length depends on patient status and the complexity of the presenting problem. Simple cases need minimal details, while complex ones need to be more detailed. The key is to use the SOAP format without adding unnecessary information. Keep it brief, keep it useful.

Before we begin, read also our blog about how to be a successful nurse practitioner.

How to Write a SOAP Note

SOAP note format consists of four main sections:

1. Subjective – The client's chief complaint, present illness, and important client behavior reported in their own words.
2. Objective – Objective data like vital signs, laboratory results, and physical examination findings. Only facts here, no opinions.
3. Assessment – Here, health professionals review the patient's status, correlate findings with medical history, and determine the most compelling problem.
4. Plan – The final section outlines individual interventions, treatment steps, referrals to another professional, and future follow-up care plans.

This format keeps documentation tidy, to the point, and useful.

Subjective

The subjective section records the patient's presentation from their own perspective. This includes the client's chief complaint, current illness, and other relevant symptoms. It prepares the stage for the patient's medical record by presenting their own account of symptoms, pain level, and concerns.

To write an effective SOAP note, try to get straightforward and direct responses from the patient. Use open-ended questions to get important information:

• What brings you in today?
• When did your symptoms start?
• Tell me about the pain or discomfort.
• Have you noticed anything that makes the pain better or worse?
• Have you ever had similar issues before?
• Are you currently on any medications?
• Do you have any history of previous medical conditions or surgery relevant to this problem?
• Has there been a change in your daily activities?
• A well-written subjective section gives the healthcare provider the context needed to understand the patient's experience before moving on to measurable data.

Objective

The objective section contains facts that can be measured. In this section, you need to document physical findings, laboratory data, and vital signs. Unlike the subjective section, this section contains factual data and no opinions.

It may include:

• Vital signs – Temperature, heart rate, blood pressure, respiratory rate
• Physical exam findings – Any noticeable observations such as swelling, wounds, or rashes
• Measurable data – Lab results, imaging tests, and test scores
• Behavioral observations – Any behavior of the client that is relevant such as agitation or confusion
• With a well-written objective section, you make sure that all the medical notes are recorded based on the facts, and you make it a lot easier for other healthcare providers to assess the patient's status.

Assessment

The assessment section brings everything together. This is the point where you explore the presenting problem using the subjective and objective sections. With clinical reasoning, healthcare providers eliminate possible causes, track improvement, and document changes in the patient's current status.

This section of a SOAP note connects the patient's history with current findings. It often includes:

• A diagnosis or working diagnosis
• How symptoms relate to medical history
• Changes in patient status since the last visit
• Response to past treatments
• This section helps other healthcare providers have an instant sense of the major issues and a baseline for the future plan.

Plan

The plan determines what comes next. This section includes suggested treatment plans, referrals, and follow-ups, if necessary. A good treatment plan enables effective communication between healthcare providers and guides future actions in a patient's care.

A sample entry here could be:

• Specific intervention – Medications, therapies, or lifestyle changes
• Follow-up care – Next visit date, monitoring progress, and future exams
• Referrals – Referring the patient to other providers as needed
• Patient instructions – What they need to do between sessions
  A clear plan section keeps everything organized, with necessary follow-ups, without leaving out essential information.

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SOAP Note Examples

Seeing actual examples makes it easier to write one. All the notes have the same SOAP structure, but the content varies with the condition of the patient. We came up with some examples to demonstrate how to write medical notes for various occasions: general medical visits, physiotherapy, and mental health. Each component helps healthcare practitioners monitor a patient's condition, convey information to other professionals, and design a successful treatment plan.

And before we give you more writing tips, read our blog post about a nursing student internship.

SOAP Note Writing Tips

Writing SOAP notes is easier with the tips we’ve put together for you: 

• Write only the essentials. Don't include extra unnecessary details, and keep the relevant information that will help other healthcare providers understand the case.
• Keep the facts within the objective area alone. Avoid opinions or hypotheses. Take down quantifiable facts, like vital signs, laboratory results, and observations.
• Follow the SOAP note format without skipping sections. Each section serves a purpose, which makes it easy to monitor the status of a patient over a period of time.
• Avoid passing judgment and personal opinions. Keep your notes brief, respectful, and medically relevant.
• Double-check for accuracy at all times. A minor mistake in medical notes can lead to miscommunication or medical errors in patient care.

To Sum Up

Throughout the article, you’ve learned pretty much everything you need to know about SOAP notes. Let’s run through the most important part one more time: 

S - Subjective: What the patient says to you, including symptoms and concerns.

O - Objective: Quantifiable information, test results, and observations that are visible.

A - Assessment: Diagnosis or clinical summary based on the above sections.

P - Plan: Future actions, treatment plans, and follow-up.

Good writing skills make a difference both in academics and healthcare. If you need help with organizing your thoughts or need a nursing research paper writing service, EssayPro offers writing help for students with case studies, research papers, and every other academic assignment.

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