SOAP note

A SOAP note is a format that may be used for writing patient notes. It stands for Subjective, Objective, Assessment, Plan.
It is widely used in the United States, and it is also used in the United Kingdom in general practice and sometimes when reviewing patients on the ward.

	Outpatient	Inpatient
Subjective What the patient says	Presenting complaint History of presenting complaint Systems review Summary of medical history and medications	Subjective description of how patient has been since last review Explore any symptoms
Objective Anything measured/ examined/tested	Patient appearance Observations Physical examination (tailor to complaint)	Patient appearance Observations (include trend and any temperature spikes) Other nursing charts, e.g. fluid balance Physical examination (tailor to complaint) Test results (lab tests, radiology etc.)
Assessment Doctor’s assessment of what is going on	Summary of the clinical problem Differential diagnosis and clinical reasoning	Summary (e.g. admission day, antibiotic/ post-op day number) Diagnosis/diagnoses/problem list
Plan	Investigations Management plans Safety-net (tell the patient when to re-seek medical advice)	Investigations Management plans

Clerking and reviewing patients