Soap Note Types, Importance, and Tips & Tricks – (With Templates And Examples) [2023]

Last Updated on September 16, 2023

Do you want to get better at writing an organized SOAP note? As a healthcare provider, it is important to write a detailed SOAP note since organized SOAP notes make the healthcare provision process faster and easier. In this article, you will see tips and tricks on how to write good SOAP notes, as well as SOAP notes examples and templates that can help you improve your writing skills.

What is a Soap Note?

SOAP is an acronym meaning Subjective, Objective, Assessment, and Plan. The SOAP note is a method used by healthcare professionals to document a patient’s medical information during a medical examination. It was developed to have easy-to-understand and comprehensive information about a patient’s medical condition.
Before Lawrence Weed created SOAP note in 1950, the method used was referred to as Problem-oriented medical record (POMR). SOAP note meaning evolved to become the standard method for documentation, making it easy for other healthcare workers to understand a patient’s treatment plan. It is important to know that progress notes in healthcare are not exactly the same as SOAP notes.

What Are The Four Parts of a Soap Note?

The SOAP note is divided into four parts: Subjective, objective, assessment, and plan. 

1. Subjective

Basically, the subjective in SOAP note is what the patient or representative tells you. The first part of the documentation involves the patient’s personal experiences, feelings, and views, and the best practices are to write these experiences in the patient’s words. The subjective component is further divided into five categories;

a. Chief Complaint (CC)

A brief statement to show the patient’s reason for hospitalization is referred to as the chief complaint (CC.) The CC can either be a symptom, previous diagnosis, or health condition. It should be able to tell what the SOAP note is all about and can be likened to the title of a document. 

Furthermore, it is possible for a patient to have multiple CC’s; the first complaint does not make it the most important one. Therefore, it is important to always ask the patient to state all of their CC and to ascertain the most compelling one.  A good example of a CC can be shortness of breath or constant headaches.

b. History of Present Illness (HPI)

This phase is where the patient will be asked about the history of the CC, from the time of the initial symptom to the present moment of consultation. The HPI starts with personal information like age, sex, the reason for the visit, and the level of symptoms experienced by the patient. 

Healthcare providers use a mnemonic to record a patient’s HPI, known as “OLDCARTS.” It is important to summarize the HPI for subsequent visits by the same patient for the same CC.

• O – Onset: “Where did the CC begin?”
• L – Location: “Where is the CC located, or where do you feel the CC?”
• D – Duration: “How long have you been feeling the CC?”
• C – Character: “Can you describe the CC?”
• A – Alleviating or Aggravating Factors: “What makes the CC worse or better?”
• R – Radiation: – “Does the CC move or stay in one location?”
• T – Temporal Factor: “Is there a time of the day when the CC is worse or better?”
• S – Severity: “How bad do you feel about the CC? Rate the level of severity?”

c. History

The next category is to document the different histories of the patient. This includes:

• Social History: There is an acronym known as HEADSS, which stands for home/environment, education/employment, activities, drugs, sexuality, and depression/suicide. The patient’s social history will give insights into the patient’s lifestyle, activities, or level of drug and alcohol intake.
• Medical History: Current and past medical condition of the patient.
• Family History: The medical history of the patient’s immediate family.
• Surgical History: Past surgery, time of surgery, and possibly the overseeing surgeon.

d. Review of System

Under the review of the system interview, the physician will try to determine the symptoms that the patient did not include, like weight loss, decreased appetite, abdominal pain, etc.

e. Allergies or Current Medications

Patients’ allergies or current medications can be recorded under the subjective component.

2. Objective

The objective in the SOAP note describes what the clinician observes from the patient. This includes the information that the healthcare provider gets about the client’s vital signs, laboratory results, weight, imagining results, and other diagnostic data. 

3. Assessment

This phase of the SOAP is where the healthcare provider assesses information on the subjective and objective parts of the SOAP note to arrive at the diagnosis. This part includes reasons for the patient’s problems, the patient’s progress since the last visit, and the patient’s treatment progress.
Progress note, meaning in medicine, represents the tools that give details about a patient’s journey to recovery, and the progress note of a patient can be recorded under the assessment category. SOAP note assessment examples include risk factors involved, assessment for the need for therapy or surgery, previous or current therapy, etc

4. Plan

Plan in SOAP notes can be described as the steps taken to make the patient better. In this section, the procedures that the patient needs to undergo to feel better are written down. This category makes it possible for future healthcare providers to know the next step of action. For each problem, you should take the following steps:

• State the test needed to resolve diagnostics ambiguities.
• Therapy or medical procedure is required.
• If there is a need for a specialist referral or consultant referral.

How to Write Soap Notes?

By following the standard structure of the SOAP note, you can create an organized note that can help you arrive at a patient’s diagnosis and treatment plan. Also, an organized SOAP note presentation makes it possible for other healthcare professionals to follow up on a patient.

What is a Soap Note Template and Examples?

In this section, we will illustrate how SOAP notes are written by giving some SOAP notes examples that can help you write a well-organized SOAP note. SOAP note PDFs by experts in the industry have different SOAP note templates for other cases. These seven examples below can also serve as SOAP notes templates:

1. SOAP Notes Example for Nurse

Nurses need to be able to write an organized SOAP note that makes it easy for the doctor, pharmacist, or other healthcare practitioners to help the patient.

a. Subjective

• Mark complained of “feeling tired and exhausted often.” He said he finds it difficult to get out of bed every morning. 
• He has been going through this for the past 4 weeks. 
• Mark has been missing work for two weeks. Mark said he could not sleep for more than 1 hour.

b. Objective

• Mark’s hygiene has not been good, and he is not eating well. 
• He looks pale and tired. 
• Mark has not been taking his medications regularly and has lost weight.

c. Assessment

• Mark’s speech rate is low, and he loses concentration regularly. 
• Mark’s slow body movement depicts depressive symptoms. 
• His communication skills are still okay, but communication is minimal. 
• Mark does not hallucinate or have any delusions. No signs of suicidal thoughts. 
• Memory is still intact, and no sign of substance usage.

d. Plan

• Mark’s diagnosis appears to be mild recurrent depressive disorder F33.0. The problem that led to the diagnosis is constantly depressed moods. 
• Interventions: Mark will attend weekly therapy. He will tell his family about his condition.
• He will participate in local community support to interact more with people. 
• He will be monitored to always take his medications. 

2. SOAP Notes Example for Occupational Therapy

SOAP note example occupational therapy is a template that occupational therapists can use. A typical soap note format for occupational therapy is shown below.

a. Subjective  

• Mark reports that “he feels energetic and extremely active.” 
• Mark also stated that he gets at least 8 hours of sleep every day.
• He also said he ensures he is eating right but is afraid he might be eating too much.

b. Objective  

• Mark attends his therapy session regularly. 
• His personal hygiene has improved greatly.
• And he does not miss his medication. 

c. Assessment

• Mark came for his therapy in a lively mood. 
• His speech was normal, and his attitude was welcoming.
• Mark’s energy level was better than in the previous therapy session, and his stamina improved significantly.
• Mark’s medication seems to be improving his condition significantly.

d. Plan

• Mark has a therapy session next week on Monday. 
• He has to continue with his medication for another two weeks.  

3. SOAP Notes Example for Counsellors

This SOAP note counseling template below can be used by drug abuse counselors, and it is different from soap note nutrition counseling.

a. Subjective  

• Rose has been battling cocaine addiction for 5 years. 
• Rose said, ‘she wants to stop, but she is finding it so difficult. 
• She also said she wants to stop the rehabilitation process. 
• Rose stated that she wants to stay sober because of her daughter.

b. Objective  

• Rose attends her appointments regularly. 
• She is also calm during her appointment. 
• Rose did not show any sign of being under the influence or acting agitated during her last session. 
• Rose’s concentration has improved, but she has still been aroused or distracted. 
• Rose has gained 3 pounds and has improved her personal hygiene.

c. SOAP note counseling 

• Rose is showing significant progress with treatment. 
• She is doing well physically as she is taking up exercises. 
• Rose’s urge for cocaine is also reducing; she feels the urge after a couple of hours rather than regularly. 
• Rose needs additional coping skills to keep her on the right path to recovery.  
• CBT treatment will be significantly beneficial to Rose in her recovery process. 

d. Plan

• Rose will undergo additional psychoeducation. 
• The therapist should use dialectical therapy techniques to address Rose’s emotional dysregulation. 
• Rose will keep attending the local support for encouragement and support. 

a. Subjective

• Chief Complaint: 45-year-old with pain in the canine tooth for 3 days. 
• HPI: Historical asymptomatic
• No medical history
• No medication conditions
• Not undergoing any medication presently
• Social history: Alcohol

b. Objective

• Vitals: Temperature is normal at 87, BP is 133/91
• Oral exam: 

• Asymmetry: Nil
• Swelling: Nil
• Temporomandibular joint dysfunction (TMI): Nil

c. Assessment

• Alcohol (1 bottle per day)

d. Plan

• Tooth extraction
• Medication 

5. SOAP Notes Example for Physical Therapy

Soap note format for physical therapy and soap note massage therapy can be the same format as below:

a. Subjective

• Sam said, ‘he does not like how his back feels”. 
• He said he felt some strain on his lower back. 
• He said he spends a lot of time on the computers, and it affects his back and neck.

b. Objective

• Sam does not work out and does not have a good sitting posture.
• Tenderness at the shoulder. 
• A body massage was provided with a concentration on the back and shoulders. 
• Sam receives some instructions on how to sit while on his computer.

c. Assessment

• Sam reported that the back pains have reduced significantly as he adheres to the new sitting position while on his computer.

d. Plan

• Regular massage. 
• Sam was advised to get an ergonomic chair.

6. SOAP Notes Example for Pediatrician

Pediatrics is a delicate part of medicine because it involves young children. As a pediatrician, you can write a pediatric mental health soap note for better and faster healthcare provision.

a. Subjective

• Mrs. Alex brought her child and complained that she eats regularly but finds it hard to sleep.
• Her child has a playgroup, and she always engages the other kids.

b. Objective

• Mrs. Alex was advised to give her daughter magnesium.

c. Assessment

• Mrs. Alex said she sleeps a little bit better now.

d. Plan

• The daughter of Mrs. Alex will undergo treatment next week.

7. SOAP Notes Example for Social Workers

Social workers are essential to different organizations like hospitals, and the SOAP note social work template below can be used by them.

a. Subjective

• John has been going through a tough time within the last couple of weeks. 
• Within the last couple of days, his condition has worsened, and depressive symptoms are beginning to set in. 
• John also stated it himself: “I am feeling depressed, and I want to shut out from everyone.”
• He said his energy levels are really low, and most times, he does not feel like doing anything.
• John said for two weeks now, he has been tired mentally and finds it difficult to sleep.
• John said, “he wishes he would not wake up anytime he eventually sleeps.”

b. Objective

• John has lost a couple of pounds in weight. 
• He does not have constant hallucinations or delusions. 
• He is taking his medication regularly. 
• He is less impulsive in his thoughts than before.

c. Assessment

• To get more insight into John’s Depression, the last session was focused on the severity of his depression. 
• Also, the aim of the therapy was to help John focus on overcoming his depression. 
• John was introduced to tools to help him heal faster.
• John communicates with people minimally, but his speech rate is normal.
• John still exhibits signs of depression as he withdraws to himself, has slow physical movement, and has abnormal quietness. 
• No hallucinations, delusions, or psychotic symptoms for 1 month now.
• John’s thinking is logical now, but he still feels suicidal when remembering some situations but has no intention to act.
• John also regularly visits his local support group and constantly communicates with his child.

d. Plan

• Therapy sessions to treat CBT will increase from twice a week to three times a week. 
• He is part of the local community service to interact more with people. 

SOAP Note Tips

To get better at writing SOAP notes, here are 5 tips by experts that can help you. 

• Do not assume the first complaint as chief complaint cc.
• Write SOAP notes at the appropriate time.
• Maintain a professional voice.
• Do not make assumptions about who would read the soap notes.
• Be specific and concise.
• Be accurate and non-judgmental.

SOAP Note Mistakes You Should Avoid

Whether you are an experienced clinician or not, it would be good to avoid these 5 common mistakes.

• Do not include unsourced opinions.
• Avoid using void language.
• Avoid repetition.
• Don’t generalize statements.
• Instead of rewriting, make adjustments.

How Do You Get Better At Writing A Soap Note  Overtime?

As a new clinician, you want to get the most out of your session with a patient. You want to take down all the important points at the right time while paying close attention to the patient. You can follow these 3 tips to help you improve at writing a SOAP Note over time:

• Improve your typing and writing skills. 
• Manage your conversation with the patient like you would type it. Then replay the encounter in your head.

Practice with templates. You can also memorize the tips using SOAP note flashcards.

How to Make Soap Notes Easy

When writing SOAP notes, it is necessary to avoid using informal slang or words. For example, statements like “The patient had a blast during the appointment.” The word “blast” is not descriptive and can mean many different things.

Also, you can practice using templates to improve your skills. The golden rule of writing SOAP notes is to make it easy for the next reader to understand. 

Conclusion

The next person reading the SOAP notes may not be a professional healthcare worker, so it is important to make it easy for anyone to understand. Many healthcare providers make the wrong assumption that the next person reading the SOAP note will be either a doctor or a nurse: Lawyers, reimbursement officers, or even insurance personnel can read SOAP notes when needed.
As much as the primary readers of SOAP notes are healthcare providers, it is important not to make it offensive just in case the patient or family member reads it. It would be wise not to pass judgment about the patient’s lifestyle or activities. 

You can also read our blog about how to become a therapist to acquire information to build a well-directed career plan.