What Are Soap Notes?

Documentation is the primary way healthcare professionals communicate with one another about patients. All nurses, including nurse practitioners and those working at the bedside, are a part of a team that can also include a number of other professionals, like doctors, physical therapists, case managers, and mental health professionals. To ensure everyone is on the same page, effective documentation is key. Effective documentation supports good patient care, so many professionals rely on standard types of document, like the SOAP method.

SOAP notes are a standardized way of documenting patient interactions and assessments. These notes are methodical, following the same steps—subjective, objective, assessment, and plan—to make sure that every clinician documents all relevant information about a patient in a way that other members of the care team can understand. 

Below, we dive into SOAP notes, covering each step in detail as well as common errors and tips for helping you write SOAP notes correctly.

What are SOAP notes?

SOAP notes are used by various healthcare professionals as a way to provide organization and structure to documentation. This technique was introduced in the 1960s by a physician named Lawrence Weed as a way to improve communication between physicians and identify relationships between various problems. 

Since its introduction, the SOAP note has been adopted by a number of healthcare-related professions, including nursing. The information included in a SOAP note is intended to help healthcare professionals assess, diagnose, and treat patients, sharing useful, organized information throughout the patient record.

In SOAP notes, each heading includes a certain type of information, as explained below. When documenting each of these sessions, it is important to remember to be thorough but to focus on documenting clear, quality information rather than every detail.

Subjective

Subjective documentation captures the patient’s personal feelings or opinions about what they are experiencing. It can also include information provided by family members or others who are familiar with the patient’s situation. The subjective information collected here is used to provide context during the later assessment and planning.

Subjective information generally includes the following information:

Chief complaint

The chief complaint is the primary problem being presented by the patient. It can be a symptom, diagnosis, or just a brief explanation of what is bothering them. That said, patients can have a number of complaints, and their first one may not be the most significant one. Nurses and other healthcare providers should encourage the patient to share all of their complaints and document everything to help with assessment and planning. 

Examples of a chief complaint can be having chest pain, feeling tired, or having shortness of breath. Patients may also say something vague, like “I’m just feeling off,” which should also be documented.

History of present illness

This is where you dive into the details of the chief complaint. Some people use the acronym OLDCARTS to help them gather appropriate information. 

• Onset: When did the chief complaint begin?
• Location: What is the chief complaint affecting?
• Duration: How long has the chief complaint been present?
• Characterization: How does the patient describe the chief complaint?
• Alleviating and aggravating factors: What causes the problem to be better or worse?
• Radiation: Does the chief complaint affect one or multiple areas?
• Temporal factor: Is it worse or better at a particular time of day?
• Severity: Rate the chief complaint on a scale of 1 to 10, with 1 being the least, 10 the worst

Here’s an example for a patient complaining of abdominal pain:

• Onset: Three weeks ago
• Location: Right upper abdomen
• Duration: Intermittent
• Characterization: Sharp, stabbing
• Alleviating and aggravating factors: Eating heavy meals and greasy food
• Radiation: Pain radiates to back and shoulder
• Temporal factor: Worse at night
• Severity: 6/7, but increases to 10 after meals

Review of systems

This section focuses on identifying symptoms that the patient may not mention or be aware of. It’s a systematic head-to-toe review covering all body systems and identifying anything that is unusual to inform the rest of the evaluation.

Objective

Objective information is that which is factual, measurable, and observable. It includes:

• Physical exam findings
• Vital signs
• Imaging tests
• Lab results
• Current medications and allergies (can be listed under either subjective or objective information)

It can be difficult to determine whether some information should be included under subjective or objective data, but remember that objective data is observable or measurable. So, for example, a patient telling you that they have abdominal pain is subjective, while observing guarding or finding abdominal tenderness to palpation is objective.

Assessment

The assessment section uses all of the subjective and objective information to determine the patient’s status. Note that this section is generally a little different for bedside nurses than it would be for physicians or nurse practitioners. Whereas a doctor or nurse practitioner may arrive at a medical diagnosis, bedside nurses cannot diagnose medical conditions, so their analysis focuses more on nursing diagnoses. 

For example, in the OLDCARTS example above, a nursing diagnosis may be acute pain, anxiety related to treatment or symptoms, or disturbed sleep pattern, while a physician or nurse practitioner is likely to arrive at a medical diagnosis like “acute cholecystitis secondary to gallstones” or document a differential diagnosis for possible causes of symptoms. 

Plan

This section essentially covers what comes next. It can include the need for consultations with other members of the care team, additional testing, and any steps that are necessary to treat the patient. The planning section is an important part of a SOAP note as it helps other members of the care team understand what has been done already and what needs to be done next, which contributes to continuity of care.

Criticism of SOAP notes

While SOAP notes are widely used, there are some criticisms of them that are worth knowing about.

Some argue that the order of the steps may not be the most logical, arguing that Assessment, Plan, Subjective, Objective (APSO) makes more sense. By placing the assessment first, it provides the most relevant information right at the beginning, making it easier to find the most necessary info quickly. 

Experts have argued that APSO is generally more relevant to ongoing patient care as it stresses the importance of the assessment and planning sections. However, they also point out that changing the order does not change the importance of the subjective and objective information. It just essentially moves it farther down the page. Research has found that APSO is a better choice for speed, accuracy, and usability, so rearranging the steps can be seen as a way to improve the flow of information and communication.

Tips for writing SOAP notes

Here are some tips for composing accurate SOAP notes: 

• Take detailed personal notes when interacting with the patient so you have all the information you need to compose a thorough note after your interaction. Generally, you will not have time to compose a SOAP note when you’re with a patient, but you should not wait too long after the interaction to document. 
• Use formal and descriptive language to describe patient interactions. For example, if a patient is crying and tells you they are sad, instead of writing, “The patient is very sad,” or, “The patient is down in the dumps,” write, “The patient was tearful and verbalized feeling sad.”
• Be concise. Don’t use flowery language. Keep it straight and to the point. 
• Avoid drawing conclusions. Instead of using, “The patient does not know the date or their name,” use, “The patient is unable to state the date of their own name when asked.” In this example, you don’t really know that the patient is not aware of the date or their name, only that they are unable to speak that information to you.
• Don’t use modifiers like “very” or “quickly” as these words are subjective and have a different meaning for everyone. 
• Avoid using pronouns if they are confusing. For example, instead of writing, “Nurse requested patient tell them their first name,” use, “This RN requested client state client’s first name.”
• Don’t be judgmental. Don’t say, “Patient states they are in a lot of pain but seems to be exaggerating as they do not appear to be hurting.” Instead, simply say, “Patient states they are in pain, rated 6/10.”

Common mistakes in SOAP notes

Building off of the tips above, here are some common mistakes when writing SOAP notes:

• Overgeneralizing subjective information. One way to avoid this is to include quotes from the patient. For example, instead of saying, “Patient reports they feel better today and have an improved appetite,” use, “Patient states their abdominal pain is a 3/10 this morning and that they were able to eat their entire breakfast.”
• Incomplete objective information. Make sure you include all of the objective data you have and collect anything you’re missing. Vital signs, test results, and assessment findings should always be included.
• Repeating subjective and objective data in the assessment section. Assessment should include your diagnosis and what you arrived at by analyzing the subjective and objective information.
• Using non-standard abbreviations. Use only standard medical abbreviations so that anyone who reads your notes can understand exactly what you mean. Most facilities or hospital systems will have their own approved list of abbreviations, and the Joint Commision, a non-profit organization that accredits and certifies healthcare organizations and programs, has a list of “Do Not Use” abbreviations to avoid.
• Waiting too long to document. SOAP notes should be documented as soon as possible after the patient interaction. Waiting increases the risk of forgetting things or mixing up one patient’s details with another’s.

Alternatives to SOAP

There are a number of alternatives to SOAP notes, though many are primarily used in behavioral health. Other types include:

• BIRP (Behavior, Intervention, Response, and Plan): BIRP notes are focused more on behavior and are more likely to be used by mental health professionals. With BIRP notes, clinicians document objective and subjective information about behavior, the interventions used to help patients reach their goals, how they responded to those goals, and a plan for the next session.
• DAP (Data, Assessment, and Plan): DAP notes are similar to SOAP notes but are more condensed, including relevant subjective and objective data, an assessment of what that data means, and a plan for interventions.
• GIRP (Goals, Intervention, Response, Plan): Like BIRP notes, GIRP notes are primarily used by mental health professionals, focusing on the patient’s therapy goals, the interventions used to help them meet those goals, how they responded to those goals, and the plan for the next session.
• PIE (Problem, Intervention, Evaluation): PIE notes are concise and problem oriented and, while they can be used in a medical setting, they’re more likely to be used by mental health professionals. PIE focuses more on the problem and the therapeutic process than the patient and may be used to focus on interventions and the response to those interventions.
• PAIP (Problem, Assessment, Intervention, Plan): PAIP notes may be used in behavioral health or case management. They’re less comprehensive than a SOAP note.

Use SOAP to keep your documentation and communication clean and precise

While there are some valid criticisms of the SOAP method, it is still one of the most common types of medical documentation used today. Understanding the SOAP method and learning how to write a note using this format can help ensure continuity of care for the patient and effective communication between all members of the care team.