How to write a SOAP note (with an example)

What does SOAP stand for in a SOAP note?

SOAP stands for Subjective, Objective, Assessment, and Plan, the four sections of a structured clinical note. StatPearls credits Lawrence Weed with developing the widely adopted SOAP note structure; his problem-oriented medical record reached a wide audience through his 1968 New England Journal of Medicine article, Medical Records That Guide and Teach.

The format does two jobs. It communicates a patient's status to everyone else on the care team, and it works as a framework for clinical reasoning: you gather what the patient tells you, add what you can measure, interpret both, and decide what to do next.

In the hospital, the SOAP format is most familiar as the daily progress note, a focused update on a patient you already know; clinic follow-up visits use the same structure.

What goes in the Subjective section of a SOAP note?

The Subjective section records what the patient reports, plus events the care team passes along, since your last note: symptoms, concerns, and changes in the patient's own terms. In a first visit it starts with the chief complaint in the patient's words and a history of present illness; in a daily inpatient note it focuses on the interval since yesterday.

You do not need to write that the patient reports each item, because readers assume everything in this section comes from the patient or the care team. Use the symptom attributes you learned for the HPI, such as onset, location, quality, severity, timing, and what makes it better or worse, when a symptom is new or changing.

• Overnight or interval events, including anything nursing or the cross-cover team flagged.
• Each active symptom: better, worse, or unchanged, in specific terms (for example, walking to the bathroom without getting short of breath).
• New complaints, even if minor, so they are addressed in the plan.
• Function that matters for the stay: eating, sleeping, pain control, bowel and bladder function, mobility.
• The patient's own questions, goals, or concerns about the plan.

What goes in the Objective section of a SOAP note?

The Objective section holds what you measured or observed today: vital signs, your physical exam, and new laboratory, imaging, and microbiology results. Keep interpretation out of this section; save words such as improving or worsening for the assessment.

Report vital signs with their range over the last 24 hours, not just a single set, and note any oxygen requirement. Write a focused exam that covers the systems relevant to the patient's problems and document what you actually examined that day. List new results with a comparison point, such as the admission value, instead of pasting every lab of the stay.

• Vital signs: current values plus 24-hour ranges and the oxygen requirement.
• Intake, output, and weight when they matter (for example, heart failure or kidney injury).
• Focused physical exam for today.
• New labs, imaging, and culture results, with trends.
• Current medications, lines, drains, and devices when relevant to the plan.

How do you write the Assessment and Plan in a SOAP note?

Start the assessment with a one- or two-sentence summary statement, then list each active problem with its current status, your reasoning, and a plan for that problem. The summary statement names the patient's key background, the main diagnosis, and the trajectory, for example improving on day 3 of antibiotics.

For each problem, say whether it is better, worse, or unchanged, and why you think so, using the subjective and objective data above. A line that only restates a diagnosis, such as pneumonia, continue antibiotics, tells the next reader nothing about your thinking. If a diagnosis is uncertain, give a short differential and explain what would change your mind.

Under each problem, the plan lists diagnostics, treatments, monitoring, consults, and patient education. Rank problems from most to least important, and close with the housekeeping items most services expect: venous thromboembolism prophylaxis, diet, lines, code status, and the discharge plan.

Some health systems put the assessment and plan first, an order called APSO, so that readers find the decision-making faster. At UCHealth in Colorado, a 2017 study found that 80.6 percent of surveyed clinicians were satisfied or very satisfied writing APSO notes, and 68.1 percent preferred reading APSO over SOAP; the survey response rate was 18 percent. Use whichever order your service uses.

What does a SOAP progress note look like? (Fictional example)

The example below is entirely fictional and describes no real patient. It shows how to organize a daily inpatient progress note; it is not treatment advice, and real care decisions follow your attending, your hospital's protocols, and current guidelines.

Header: Hospital medicine progress note, hospital day 3, with the date and time of the note.

Subjective: No acute events overnight. Cough is less frequent and sputum is lighter. Breathing is easier; able to walk to the bathroom without stopping. No chest pain. Ate most of breakfast. Nursing reports no fevers and no supplemental oxygen since yesterday afternoon.

Objective: Tmax 37.4°C over 24 hours (38.6°C on admission). HR 84 to 92, BP 122 to 134 over 70 to 78, RR 16 to 18, SpO2 94 to 96 percent on room air (91 percent on 2 L nasal cannula on admission). Exam: alert, speaking in full sentences, no increased work of breathing; crackles at the right lung base, less prominent than yesterday; regular rhythm, no murmur; no leg edema. Labs: WBC 11.2 (14.8 on admission); creatinine 0.9, stable. Fingerstick glucose 142 to 198 mg/dL. Admission blood cultures: no growth at 48 hours. Medications: IV ceftriaxone and azithromycin (antibiotic day 3), basal insulin with correction-scale insulin, home lisinopril, subcutaneous enoxaparin.

Assessment and plan: 68-year-old with type 2 diabetes and hypertension admitted with right lower lobe community-acquired pneumonia, clinically improving on day 3 of antibiotics: afebrile for more than 24 hours, off oxygen, eating, and with a falling white count.

1. Community-acquired pneumonia, improving. Resolving fever, oxygen need, and leukocytosis suggest response to therapy, with no sign of complication. Plan: transition to oral antibiotics today if stable on reassessment; continue therapy until clinically stable and for at least 5 days total; follow final blood cultures; ambulate with nursing and use incentive spirometry.

2. Type 2 diabetes with hyperglycemia during acute illness. Glucose 142 to 198 on basal plus correction insulin; home metformin held during admission. Plan: continue the current insulin regimen per hospital protocol; review the home regimen before discharge.

3. Hypertension, controlled. Blood pressure in range on the home regimen. Plan: continue home lisinopril.

Prophylaxis and disposition: enoxaparin for VTE prophylaxis; carbohydrate-consistent diet; full code, confirmed with the patient on admission. Anticipate discharge home in 1 to 2 days if tolerating oral antibiotics on room air, with primary care follow-up. Signed with the author's name and credentials.

What are the most common SOAP note mistakes?

The most common SOAP note mistakes are copying forward old text, an assessment that only repeats data, and contradictions between sections. The Joint Commission's Quick Safety advisory on copy and paste warns that the function can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient's chart; it cites a literature review by the Partnership for Health IT Patient Safety in which one study of diagnostic errors found that copy and paste led to 2.6 percent of the errors in which a missed diagnosis required additional unplanned care. Experts consulted by that workgroup agreed that information that has not been read and edited should never be copied.

• Carrying forward yesterday's subjective or exam without re-checking it, so the note describes a patient who no longer exists.
• An assessment that lists diagnoses without status or reasoning.
• Interpretation in the Objective section, or raw data repeated in the Assessment.
• Contradictions, such as no fever in the subjective while the vital signs show 38.5°C.
• A stale plan: tests already done, medications already stopped, or consultants already signed off.
• A new problem raised by the patient or nursing that never reaches the assessment.
• Data dumps: every lab of the stay pasted in, burying what changed today.
• Judgmental or vague wording, such as noncompliant or refuses, instead of a neutral description of what happened and why.
• Entries that are not dated, timed, and signed; federal hospital rules require every medical record entry to be dated, timed, and authenticated.

How is a SOAP note different from an H&P and a discharge summary?

An H&P is the comprehensive admission note, a SOAP progress note is the focused daily update, and a discharge summary closes the hospital stay. All three share the same reasoning, data first and then assessment and plan, but they differ in scope and timing.

Under the Medicare Conditions of Participation, the history and physical must be completed no more than 30 days before or 24 hours after admission (with an update if done beforehand) and before surgery or a procedure requiring anesthesia. The record must include a discharge summary covering the outcome of the hospitalization, the disposition, and provisions for follow-up care, and the record must be completed within 30 days after discharge. Progress notes have no single federal deadline, but the record must describe the patient's progress and response to medications and services, and hospital and medical staff rules set how often progress notes are written.

The federal interoperability standard (USCDI) draws the same line, defining a progress note as a narrative summary of a patient's interval status during an encounter. The table on this page compares the three notes.

How can interns write better SOAP notes faster?

Interns write better notes faster by pre-rounding with a checklist, writing the assessment before polishing the rest, and editing templates instead of copying old notes. For a quick self-check, use the nine qualities in the PDQI-9, a validated research tool for rating physician notes: up to date, accurate, thorough, useful, organized, comprehensible, succinct, synthesized, and internally consistent.

Length does not add value on its own. Since 2023, the CPT guidelines for hospital inpatient and observation visits base the visit level on medical decision making or time; the extent of the history and exam is not an element in choosing the level, though a medically appropriate history and/or exam is still documented when performed. If you want structured practice before or during intern year, ProMed United's Virtual Intern Year includes SOAP progress notes graded against a rubric.

• Pre-round the same way every day: overnight events, vital sign trends, intake and output, new results, medication changes, and nursing concerns.
• Rewrite the one-line summary daily so it reflects today, not admission day.
• Draft the assessment and plan first, then fill in only the subjective and objective data that support it.
• Use templates and automatic data pulls, but delete what does not matter and verify anything pulled in.
• Write for every reader, including the patient: clear wording, few abbreviations, and neutral language.
• If something important happens after you sign, add a dated and timed addendum rather than changing the original note, following your hospital's policy.
• Ask your senior resident or attending for a strong example note from the service, since templates and expectations vary.