How to Write SOAP Notes: A Guide to Structured, Evidence-Based Documentation

Clinical documentation forms the foundation of safe, effective, and accountable healthcare. However, inconsistent or unclear documentation can contribute to communication gaps and potential errors. 

In today’s healthcare environments, well-structured notes are essential for supporting clinical reasoning, care continuity, interdisciplinary collaboration, legal clarity, and quality assurance.

The SOAP format—Subjective, Objective, Assessment, Plan—originally developed to support problem-oriented medical records, offers a widely adopted framework for clinical documentation across many healthcare settings. Its structured design helps promote clarity, consistency, and organized clinical thinking.

This guide provides healthcare providers with key principles and practical strategies for writing effective SOAP notes, helping to enhance documentation quality and support comprehensive patient care.

What are SOAP Notes, and What’s Their Purpose?

SOAP notes originate from the problem-oriented medical record (POMR) framework. They were designed to foster clear, problem-focused clinical documentation. 

SOAP notes offer a structured format for healthcare providers to document patient care, supporting clear communication and continuity of care.

SOAP notes are commonly used in:

• Medicine
• Nursing
• Mental health
• Physical therapy
• Speech-language pathology
• Allied health fields

Their role in supporting interdisciplinary communication, enabling retrospective case review, and promoting defensible clinical documentation makes them a valuable component of modern healthcare practice.

The Four Components of a SOAP Note

• Subjective (S): The patient’s perspective—reported symptoms, experiences, lifestyle factors, and concerns. Including direct quotes can enhance accuracy.
• Objective (O): Observable findings—vital signs, physical examination results, laboratory data, imaging reports, and clinician observations.
• Assessment (A): The clinician’s clinical interpretation—diagnosis or differential diagnoses informed by subjective and objective data.
• Plan (P): Next steps—treatment considerations, referrals, follow-up recommendations, and patient education.

When and How to Use SOAP Notes

SOAP notes can be useful for documenting:

• Single clinical encounters
• Ongoing therapy or counseling sessions
• Medication management visits
• Care handoffs

They are applicable across settings such as:

• Acute care
• Ambulatory clinics
• Behavioral and mental health services
• Telehealth encounters
• Home-based healthcare

It’s considered best practice to document SOAP notes promptly after each clinical session, using secure electronic health record (EHR) systems.

Benefits of SOAP Notes

• Help improve the clarity, accuracy, and completeness of clinical records
• Support clinical reasoning and decision-making
• Facilitate communication among members of the healthcare team
• Aid in meeting payer and/or regulatory documentation requirements
• Contribute to defensible documentation in the event of audits or legal review
• Encourage reflective practice and support ongoing professional development

Writing Each SOAP Note Section Effectively

A clear and well-organized SOAP note helps document patient care and facilitates communication among healthcare providers. The following sections outline how to structure each component of the note.

Subjective Section

Begin with the chief complaint (CC). A structured approach such as OLDCART can help organize symptom details:

• Onset
• Location
• Duration
• Characteristics
• Aggravating and alleviating factors
• Related symptoms
• Treatments that have been attempted

Additional elements to include:

• Relevant medical, surgical, family, and social history
• Review of systems (ROS), as appropriate for the visit
• Direct quotes from the patient to provide context and preserve the patient’s perspective

Objective Section

Document measurable and observable information:

• Vital signs
• Physical examination findings
• Laboratory and imaging results
• Observations of behavior or appearance (such as mood, affect, speech, orientation)

This section should focus on factual data. Interpretation and clinical conclusions belong in the Assessment section.

Assessment Section

Summarize clinical impressions and reasoning:

• List confirmed diagnoses and any relevant coding
• Include differential diagnoses, if appropriate
• Support conclusions by linking them to the information documented in the Subjective and Objective sections
• Present information in a clear and concise manner

Plan Section

Document the next steps in care:

• Treatments or interventions to be provided
• Medications to be prescribed or adjusted
• Referrals to other healthcare providers or services
• Patient education topics discussed
• Recommended follow-up timeline
• Notes on informed consent or risk-benefit discussions, when applicable

Formatting and Style Tips

• Use a clear, professional, and objective tone
• Follow institutional formatting guidelines (paragraph or bullet points)
• Avoid non-standard abbreviations
• Ensure that the note can be easily understood and used by other members of the healthcare team

Optimizing SOAP notes: Compliance and efficiency

Clear, well-structured SOAP notes contribute to high-quality documentation that supports clinical care, professional standards, and organizational requirements. 

The following best practices can help optimize both compliance and efficiency.

Clear and Purposeful Documentation

Thorough and consistent SOAP notes not only form a crucial part of the medical record but also support clinical continuity, communication among care teams, and transparency with patients. While they can serve legal and billing purposes, their primary function is to document clinical reasoning, guide care, and demonstrate progress over time.

Tips for Effective and compliant Documentation:

• Accurately describe patient concerns, clinical impressions, and treatment plans using clear, concise language.
• Use appropriate diagnostic and procedural codes (ICD-10 and CPT/HCPCS) when applicable to reflect care provided.
  • Example: F33.1—Recurrent depressive disorder
  • Example: 90837—60-minute psychotherapy session
  • Ensure records support the frequency, duration, and nature of care, while illustrating clinical decision-making and patient response.
  • Align documentation with relevant professional, institutional, and payer expectations to ensure clarity and compliance, while prioritizing the integrity of patient care.

Strategies for Efficient SOAP Note Writing

Efficient documentation supports timely and accurate record keeping without sacrificing quality. Consider these time-saving strategies:

• Use approved templates and auto-populated fields thoughtfully, ensuring information remains accurate and personalized.
• Document as soon as possible after each clinical session to enhance completeness and accuracy.
• Utilize mobile documentation tools or voice-entry features if supported by the electronic health record (EHR) system.
• Incorporate standardized phrases or dropdowns where appropriate to improve consistency and efficiency.

Common SOAP Note Pitfalls to Avoid

Be mindful of the following common documentation issues:

• Including unnecessary or irrelevant details (over-documentation)
• Recording assessments that don’t clearly reflect clinical reasoning
• Writing plans that are vague or omit follow-up steps
• Re-using prior notes (copy-forward) without updating content to reflect the current visit

Alternative Documentation Formats

Although the SOAP format remains a common standard, some clinical settings or specialties may benefit from alternative documentation structures. 

These variations are designed to meet specific workflow needs, enhance efficiency, or better capture certain types of clinical information. Selecting the appropriate format should be guided by clinical context, patient needs, and institutional policies.

APSO (Assessment, Plan, Subjective, Objective)

This format places the Assessment and Plan sections at the beginning of the note, followed by Subjective and Objective data. It’s often used in fast-paced environments, such as acute care or outpatient settings, where quick access to clinical decision-making and next steps is a priority.

SOAPE (Subjective, Objective, Assessment, Plan, Evaluation)

SOAPE adds an Evaluation section to the traditional SOAP structure. This is commonly used in rehabilitation, skilled nursing, and therapy disciplines to track progress toward functional or therapeutic goals over time.

Narrative Format

A free-text documentation style is often preferred in specialties such as mental health, palliative care, or complex care management. Narrative notes allow for a more comprehensive description of the patient’s history, psychosocial context, and nuanced clinical reasoning that may not fit neatly into structured formats.

Each format offers advantages and potential limitations. Healthcare providers should select the format that best supports accurate, clear, and efficient documentation within the requirements of their practice setting.

Frequently Asked Questions (FAQs)

Below are common questions about writing and using SOAP notes across various healthcare settings. This information is intended for educational purposes and should be adapted to fit clinical context and institutional guidelines.

How long should a SOAP note be?

SOAP notes should be concise yet complete, focusing on key clinical elements relevant to the visit. The level of detail may vary based on the care setting and type of service provided.

What’s the difference between SOAP and DAP notes?

DAP notes (Data, Assessment, Plan) combine subjective and objective information into a single Data section, providing a more streamlined structure. SOAP notes maintain separate Subjective and Objective sections, which may offer greater clarity in certain types of clinical documentation.

Can SOAP notes be used for group sessions?

Yes. SOAP notes can be adapted for group settings by documenting relevant group dynamics, shared interventions, and individual participation where appropriate. To protect privacy, avoid including identifying details about other participants in any individual’s record. Each participant’s chart should focus on their own engagement, response, and progress, even when the session context is shared. This helps maintain confidentiality while still capturing clinically relevant information.

What should I include in a SOAP note for pediatric patients?

In addition to standard SOAP elements, it may be helpful to include parent- or caregiver-reported concerns, developmental milestones, observational data, and guidance provided to caregivers.

Key Takeaways

• Alternative formats such as APSO, SOAPE, and narrative notes can be useful in specific clinical contexts and should be selected based on the needs of the patient, care setting, and professional guidelines.
• SOAP notes provide a widely used, structured format for documenting patient care, helping organize clinical information into Subjective, Objective, Assessment, and Plan components.
• Clear and consistent SOAP notes support effective communication among healthcare providers and contribute to continuity of care, clinical decision-making, and quality assurance.
• The format is adaptable across various care settings, including acute care, outpatient clinics, behavioral health, rehabilitation, telehealth, and home-based services.
• Timely, accurate SOAP notes contribute to well-documented care and should be completed promptly in accordance with institutional policies.