Over the years I have shared my "SOAP" notes with all of you assuming everyone knows what a SOAP note is and why it is used.

For all aspiring doctors, the SOAP note is the standard for medical evaluation entries made in clinical records. The SOAP note is written to improve communication among all those caring for the patient to display the assessment, problems and plans in an organized format. SOAP is an acronym. The letters S-O-A-P stand for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN.
SOAP notes are brief and to the point. For example, they give:

1--Date and purpose of the visit
2--The patient’s symptoms and complaints
3--The current physical exam: patient's height, weight, temperature, pulse, blood pressure, visual acuity, lab data and results of studies, reports, assessments
4--The current formulation and plan for the patient
S - O - A - P


1. SUBJECTIVE — These are symptoms the patient verbally expresses or as stated by a significant other.
2. OBJECTIVE — These objective observations are what the doctor assesses and include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

3. ASSESSMENT — Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

4. PLAN — The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, Return to clinic in 1 week), and follow-up directions for the patient.
Here is an example of a SOAP note:
Patient Name: Jane Doe DOB: 12/31/1961


Record No. K-6112r809

Date: 09/09/1999

S—Pt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next year and she would like to begin working toward a weight loss goal that is realistic.

O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75
HEENT is neg, Heart is RRR without murmurs, Lungs are clear, abdomen is soft, nontender, with active bowel sounds. Extremities reveal no edema

A—Obese at 183% IBW, hypercholesterolemia

P—Risk Factors of diabetes and heart disease discussed. Weight loss is in her best interest. She may want to consider a personal trainer. Names of local trainers given. Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie diet with walking 20 minutes per day. She was also encouraged to start a resistance exercise training session. Instructed Pt on lower saturated fat food/carb choices and smaller food portions. Follow-up in one month.