- 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 |
