Q&A for How to Write a Soap Note

The O can stand for either “objective” or “observations.” This section of the note covers objective data that you observe during the examination or evaluation of the patient (e.g., their vital signs, laboratory results, or measurable information like their range of motion during an exam).

A good SOAP note should be concise, professional in tone, and specific. Avoid anything that sounds judgmental or overly positive or negative toward the patient. Review the language to make sure it’s clear (e.g., check your pronouns to make sure they aren’t confusing and it’s clear who/what you’re referring to).

A variety of healthcare professionals use SOAP notes to help them assess their patients. This can include doctors, counselors, physical therapists, and emergency medical technicians. SOAP notes are especially helpful for sharing information between different providers who are treating the same patient.

Subjective: Whatever the patient is telling you: "I feel cold," "my hands are numb," etc. Objective: Whatever you observe: Patient is shivering, lips are blue etc. Assessment: General Observation. Plan: Your Tx: warm fluids, remove wet clothing etc.

Everything should be recorded for your benefit and your clients. If they should see someone else later on, that person treating them needs to know all the details.

Any motions that patients do themselves. Passive would be you doing it for them.