SOAP note
Also called SOAP
A SOAP note structures a clinical entry as Subjective, Objective, Assessment and Plan, separating what the patient reports from what you found and concluded.
Why it matters in a workup
Subjective holds the history. Objective holds examination findings and results. Assessment holds your interpretation and differential. Plan holds the actions.
The value of the format is the separation. A reader can trust your findings even when they read your interpretation differently.
Put it into practice
- Keep findings out of the assessment section
- Put the working diagnosis at the top of the assessment
- Give every plan item an owner
Frequently asked questions
Is a SOAP note suitable for a clinic letter?
The same separation works in a letter, often under fuller headings such as history, examination, assessment and plan.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Structured noteA structured note follows fixed headings, such as history, findings, assessment and plan, so omissions stand out and readers find information fast.
- Differential diagnosisA differential diagnosis is a ranked list of the conditions that could explain a patient's problem, with the reasoning for each position.
- Working diagnosisA working diagnosis is the explanation you act on until new information confirms or replaces it, usually the top of your differential.