• 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.

Components of a SOAP note

 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
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