How to Write SOAP Notes with Templates & Examples

SOAP Note Acronym Breakdown:

• S – Subjective: The patient’s subjective report of how they feel, what they are experiencing, or their perception of a problem.
• O – Objective: Objective, measurable observations made by the healthcare provider, such as vital signs, physical exam findings, and lab results.
• A – Assessment: The healthcare provider’s professional assessment of the situation, often including a diagnosis or a statement of the problem.
• P – Plan: The plan for the next steps in treatment, which could include changes in medication, new therapies, or follow-up appointments.

Difference between SOAP and DAP Notes

SOAP and DAP notes, while both essential in patient care documentation, exhibit key differences in their structure and focus. Understanding these distinctions is crucial for healthcare professionals:

Starting Point:

• SOAP Notes: Begin with Subjective information, prioritizing the patient’s personal perspective and feelings.
• DAP Notes: Start with Data, emphasizing objective information and observations first.

Content Emphasis:

• SOAP Notes: Provide balanced attention to subjective experiences and objective data.
• DAP Notes: Place greater emphasis on the therapist’s or clinician’s observations and the patient-reported data.

Structure:

• SOAP Notes: Require a comprehensive approach, integrating detailed subjective narratives with objective data, assessments, and plans.
• DAP Notes: Often follow a more streamlined structure, potentially allowing for quicker compilation.

For a detailed understanding of DAP notes, check out our dedicated article on DAP Notes.

Difference between SOAP and BIRP Notes

Comparing SOAP and BIRP notes reveals distinct approaches to patient documentation, particularly in terms of structure and content focus:

Focus on Behavior:

• SOAP Notes: While encompassing behavior in the Subjective and Objective sections, they do not specifically start with or emphasize behavior alone.
• BIRP Notes: Begin with Behavior, focusing explicitly on the patient’s behaviors and their context.

Response and Intervention:

• SOAP Notes: Generally integrate intervention strategies and patient responses within the Plan section.
• BIRP Notes: Clearly separate Intervention (therapeutic actions) and Response (patient’s reaction) as individual components.

Usage Context:

• SOAP Notes: Versatile and used across various healthcare fields, including medical, therapeutic, and mental health settings.
• BIRP Notes: Often employed in settings focused on behavior modification and mental health services.

For further insights on BIRP notes, we recommend exploring our article on BIRP Notes.

SOAP Notes are utilized by a diverse range of healthcare and therapy professionals. Their structure and clarity make them suitable for various settings and purposes. Here’s a list of professionals who commonly use SOAP Notes:

1. Nurses: For documenting patient visits, symptoms, treatments, and nursing care plans.
2. Psychotherapists: To record mental health sessions, therapeutic interventions, and patient progress.
3. Pediatricians: In child patient care, focusing on growth, developmental milestones, and parental concerns.
4. Social Workers: Utilized in case management, particularly in mental health and family services.
5. Psychiatrists: For recording mental health diagnoses, treatment plans, and medication management.
6. Therapists: In documenting therapy goals, session interventions, and patient progress.
7. Counselors: To note emotional and mental health sessions, coping strategies, and counseling session content.
8. Occupational Therapists: For documenting progress in daily living skills, functional goals, and rehabilitation plans.
9. Dentists: In dental care for recording oral health assessments, procedures, and treatment plans.
10. Speech Therapists: To document speech and language assessments, progress, and therapeutic interventions.
11. Physical Therapists: For recording patient mobility, pain levels, physical assessments, and rehabilitation plans.
12. Medical Practitioners: Across various specialties in medicine for general patient care, diagnosis, and treatment planning.
13. Massage Therapists: In documenting therapy sessions, focusing on muscular issues, client response, and treatment plans.
14. Acupuncturists: For noting patient symptoms, treatment response, and acupuncture point selection.
15. Dermatologists: To document skin examinations, dermatological conditions, and treatment plans.

Each specialty adapts the SOAP format to their specific requirements, ensuring detailed and effective patient care documentation. This versatile format enhances communication among healthcare providers and contributes to the continuity and quality of patient care.

SOAP Notes are fundamental in healthcare for several key reasons, each contributing to their widespread use and importance:

• Comprehensive Patient Care: They ensure a thorough record of patient encounters, aiding in accurate diagnosis and effective treatment planning.
• Clear Communication: The standardized format allows for easy comprehension among various healthcare providers, essential for coordinated care and when transitioning between services.
• Consistent Documentation: SOAP Notes provide uniformity in documenting patient visits, critical for tracking long-term patient progress and treatment efficacy.
• Legal and Ethical Record: They act as a legal document, recording the care provided and safeguarding ethical treatment standards.
• Educational Tool: In training settings, they serve as practical examples for students and trainees, demonstrating real-world application of clinical assessment and planning.
• Facilitation of Billing: Detailed SOAP Notes are often necessary for insurance billing and reimbursement, linking patient care with financial aspects of healthcare.
• Quality Control: Regular review of SOAP Notes can identify trends and areas for improvement in patient care, leading to enhanced outcomes and patient satisfaction.

Overall, SOAP Notes are integral to the clinical workflow, ensuring quality, continuity, and accountability in patient care across the healthcare spectrum.

1. For Nurses

SOAP Note Example for Nurse:

S: “I feel extremely tired lately.”
O: BP 135/85, HR 78, fatigued appearance.
A: Possible dehydration and overexertion.
P: Increase fluid intake, recommend rest, follow-up in 2 days.

For more nurse-specific SOAP note templates, check out our dedicated article.

2. For Psychotherapists

SOAP Note Example for Psychotherapist:

S: “I’ve been feeling overwhelmed at work.”
O: Anxious demeanor, avoids eye contact.
A: Work-related stress.
P: Implement stress-reduction techniques; schedule weekly sessions.

Explore further with our article on therapy progress notes.

3. For Pediatricians

SOAP Note Example for Pediatricians:

S: Parent reports frequent earaches.
O: Mild redness in left ear, normal growth.
A: Possible otitis media.
P: Prescribe antibiotic, recheck in one week.

Delve deeper into pediatric SOAP notes in our specialized article.

4. For Social Workers

SOAP Note Example for Social Worker:

S: Client feels isolated.
O: Limited social interactions, adequate living conditions.
A: Social isolation.
P: Facilitate community engagement, regular follow-ups.

For more, see our article on SOAP notes for social workers.

5. For Psychiatrists

SOAP Note Example for Psychiatrist:

S: Reports feeling hopeless.
O: Flat affect, coherent speech.
A: Major depressive disorder.
P: Adjust antidepressant dosage; bi-weekly therapy sessions.

6. For Therapists

SOAP Note Example for Therapist:

S: “I’m struggling with anxiety.”
O: Increased heart rate, reports difficulty sleeping.
A: Generalized anxiety disorder.
P: Cognitive-behavioral therapy, mindfulness exercises.

More on therapist progress notes can be found in our detailed article.

7. For Counselors

SOAP Note Example for Counselor:

S: “I feel undervalued at work.”
O: Appears agitated, speaks rapidly.
A: Low self-esteem issues.
P: Self-esteem building exercises, assertiveness training.

For more counseling-specific notes, see our article on counselor session notes.

8. For Occupational Therapists

SOAP Note Example for Occupational Therapist:

S: Difficulty with dressing independently.
O: Limited range of motion in arms.
A: Reduced upper body mobility.
P: Therapeutic exercises, adaptive dressing tools.

Our article on occupational therapy SOAP notes offers further information.

9. For Dentistry

SOAP Note Example for Dentistry:

S: “My tooth hurts when I chew.”
O: Cavity in the lower molar.
A: Dental caries.
P: Schedule filling, advise on oral hygiene.

Explore dental-specific SOAP notes in our comprehensive article.

10. For Speech Therapy

SOAP Note Example for Speech Therapy:

S: Parent reports stuttering in conversations.
O: Disfluencies observed in speech.
A: Stuttering.
P: Speech therapy focusing on fluency techniques.

Our article on speech therapy SOAP notes provides additional examples and templates.

11. For Physical Therapy

SOAP Note Example for Physical Therapy:

S: “My knee hurts when I walk.”
O: Swelling around the knee, limited flexion.
A: Knee osteoarthritis.
P: Strengthening exercises, hot/cold therapy.

For more on physical therapy SOAP notes, read our specific article.

12. For Medical

SOAP Note Example for Medical:

S: “I’ve had a cough and fever for three days.”
O: Temperature of 101°F, congested lungs.
A: Suspected pneumonia.
P: Prescribe antibiotics, rest, fluid intake.

13. For Massage Therapy

SOAP Note Example for Massage Therapy:

S: “My shoulders are always tense.”
O: Noticeable tightness in trapezius muscles.
A: Muscle tension due to poor posture.
P: Therapeutic massage, posture correction advice.

14. For Acupuncture

SOAP Note Example for Acupuncture:

S: “I feel stressed and have headaches.”
O: Rapid pulse, red tongue tip.
A: Liver Qi stagnation.
P: Acupuncture on liver meridian points, bi-weekly sessions.

Our article on acupuncture SOAP notes offers further insights.

15. For Dermatology

SOAP Note Example for Dermatology:

S: “There’s a recurring rash on my arms.”
O: Eczematous patches on both forearms.
A: Atopic dermatitis.
P: Topical corticosteroids, moisturizer, follow-up in 4 weeks.

For more dermatology-specific notes, explore our dedicated article.

SOAP Notes are an indispensable tool in the healthcare and therapy professions. They offer a standardized yet flexible format for documenting patient care, ensuring clarity, continuity, and comprehensiveness in patient treatment and communication among professionals. With their widespread use across various fields, SOAP Notes continue to be a foundational element in delivering quality healthcare services.