19+ SOAP Note Examples in PDF


Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns use a SOAP note to communicate effectively to their colleagues about the condition of the patient as it is essential when providing a cure for the diagnosis and giving medical or surgical treatment. In this article, we will discuss the fundamental of a SOAP note in general. Continue reading to broaden your thoughts pertaining to these documents and enhance your skills in writing one.

SOAP note facilitates a standard method in showing patient information. When everyone in the medical field uses different formats, it gets a tad bit confusing when a patient’s status is being reviewed. This may result in a bad or incorrect diagnosis or treatment.

Psychiatric SOAP Notes

Psychiatry Follow-Up SOAP

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Psychiatric SOAP Example

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Surgery SOAP Note

Post surgery Follow-Up Note

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Daily SOAP Note

Daily SOAP Sample

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Asthma SOAP Note Example

Asthma SOAP Note

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What Is a Soap Note?

A SOAP note is a method of documentation that is employed by health care professionals to write data and records to make a patient’s char, along with other documents. Check progress notes for more. Health care providers including doctors and clinician use a SOAP note to have a standard format for organizing patient information as well as the patient’s medical conditions and issues. You should know that the acronym of SOAP is Subjective, Objective, Assesment and Plan.

How to Write a Good Soap Note:

To write an effective SOAP note, you must follow the format that is mentioned below:

  • S— Write first the subjective portion (the “S”). Write your impressions on the patient. This also includes the patient’s levels of awareness, mood, willingness to participate, etc. It also refers to the observations that are verbally expressed by the patient, and these are called symptoms. You may try and use field notes examples & samples.
  • O— Followed by the objective portion (the “O”). This is where you write all the measurable data, such as vital signs, pulse respiration, and body temperature.
  • A— Then the assessment portion (the “A”). The interpretation os the diagnosis of the patient. 
  • P— Last but not least, the plan portion (the “P”) of the note. This is where you write how you are going to address the patient’s issues. Check nursing note samples for more.

SOAP Note Example

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Patient SOAP Sample

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Prenatal SOAP

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SOAP Note Sample

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Physician SOAP Note

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The 4 Parts of a Soap Note

1. Subjective

The subjective part describes the patient’s condition in the form of a narration. This is where you make your observations based on the condition or complaint which the patient expresses verbally. This also shows why the patient came to the doctor in the first place for the doctor’s note.

The subjective portion includes:

  • Onset: Determine from the patient when the first symptoms have started.
  • Location: This refers to the part of the body where the pain is located (if the pain is present).
  • Character: This refers to the enduring pain the patient had like stabbing dull, sharp, etc.
  • Alleviating factors: What drugs, treatments, activities or posture aggravates/eliminates symptoms.
  • Radiation: This refers to the place on the body where the pain radiates.
  • Additional symptoms: If there are any related or unrelated significant symptoms associated with the main symptoms. Check examples of notes for more.

2. Objective

This part of the note contains measurable data as this involves data that you can hear, smell, see and feel. So, dealing with your sensory organs. This also includes the patient’s condition or data that are repeatable and traceable.

  • Measurements of the patient, such as age, weight, and height
  • Vital signs
  • Pulse Respiration
  • Body temperature
  • Results from physical examinations, such as posture, bruising, and abnormalities
  • Lab results

You might also want to see welcome note examples and samples that would be of great help to you.

3. Assessment

The assessment plan is the physician’s medical diagnoses or the condition of the patient. In some cases, the assessment may have one clear diagnosis, and in some other cases, it may include several diagnosis possibilities.

4. Plan

This is the last section of a SOAP note. This is where you write how you are going to address the patient’s condition and issues. It may also involve requiring an additional test or two, just to verify a diagnosis or a treatment that is perfect to treat the patient’s disease. Medical notes can be of great help to you as well.

Psoriasis SOAP Sample

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Pediatric SOAP Example

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SOAP Note Format

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Clinical SOAP Note

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Orthopedic SOAP Example

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SOAP Note Example

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SOAP Note in PDF

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Sample SOAP Note

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Simple SOAP Note

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Basic SOAP Note

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Advantages and Disadvantages of SOAP Notes:

A SOAP note is an effective document that can be used to keep track of the progress of a certain patient. Similarly, this is divided into four parts, which are subjective, objective, assessment, and plan. However, just like any paper, its use has both advantages and disadvantages. Let’s see both:

Advantages:

1. It is standard and traditional.

SOAP notes follow a format in recording the medical situation of a patient and this can be used by health providers. Thus, it is clear that most of the clinicians and other medical personnel are already familiar with this.

2. It is comprehensible and simple for clinicians.

SOAP notes use a specific format that is distinctly divided into four sections, it would be much easier for the health providers to document the case of every patient easily this way. Further, clinicians would also have a certain basis on which details and data should be considered while evaluating their subjects.  They could also indicate the specific assessment and plan with their gathered information. Needless to say, the usage of these noted helps medical professionals. 

Disadvantages:

1. It is topic-bounded.

Since SOAP notes only cater to the four major portions, there are specific topics that are barely included in the document. Accordingly, only the subjective, objective, assessment, and plan sections are considered in this paper. Physiotherapists claimed that these documents are limiting their records of their patient’s condition.

2. Assessment and Plan portions are hard to find.

Concerning its format, since the assessment and the plan sections are located at the end part, it could be a challenge for the medical personnel to locate the information included in these brackets. Even with the use of an electronic system, it needs several scrollings to view a few pieces of information. This inconvenience could also be worsened by the lengthy content of the preceding sections.

3. It is time-consuming.

It takes time to review and maintain an updated and clean problem list. Since its main function is to evaluate the progress of a patient’s condition, change is unavoidable in the process. Thus, it needs to be regularly modified. Considering that these components are related to each other, some changes in the preceding portions could make a huge difference to the whole document.

4. Understanding it could be challenging for laymen.

Though these notes are comprehensible for most of clinicians, the opposite seems to happen to most of the patients and people who are not part of the medical society. Due to its massive use of acronym, abbreviation, and jargon, it could be difficult for some laymen to understand these kinds of stuff.

A SOAP note has its benefits that provide systematic documentation and evaluation to every individual patient’s condition. Nonetheless, on the other hand, there are shortcomings concerning its usage. Overall, this kind of SOAP notes is pretty effective and useful. though there is always room for improvement.

 

Tips for Writing a SOAP Note:

Here are some basic tips on how to write a SOAP note:

  1. Write a thorough SOAP thank-you note that you can refer to during rounds. It is hard to remember specific things about an individual patient, such as lab results, vita sins, etc.
  2. Organize your thoughts before writing a SOAP note. Ask yourself if do you have to write everything in the same orders as the patient expressed it.
  3. Take your time in writing the information that you need to include in your free note.
  4. Do not overload your note with too many details. If you have only the total information, then make the formal report because adding some basic information will not help. If the patient doesn’t feel a specific pain, then you do not have to write it.
  5. You are writing for other health care providers. It is acceptable if y9ou use medical terms and abbreviations to make the SOAP notes brief. You must also know what short forms are acceptable and easily understandable. You can also take a look at the therapy note samples that are available online for more.
  6. Your note should only last for five minutes when presenting it. If your blank notes are organized and well-structured then you can present it at least five minutes.
  7. You can also use the standard SOAP formats, which can help you organize your notes in the most effective way possible.

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