What exactly are SOAP notes?

What exactly are SOAP notes?

A four-step template for patient charting that's essential for consistent documentation and communication.

The ABC's of SOAP Notes for Practices

SOAP refers to Subjective, Objective, Assessment, and Plan—a standardized method of documenting patient encounters. The purpose of SOAP notes is to provide a roadmap to concisely record patient information efficiently and accurately. The notetaking method also makes it easier to share patient information between clinicians in a way that minimizes confusion and misinterpretation.

There are four parts to a SOAP note:

Subjective

This is the patient’s complaint—what brings them to a physician’s office. It includes symptoms, when they started, the frequency and severity of the symptoms, the region of the body affected, and other relevant information such as family history, social history, and past and present illnesses.

Objective

This section represents measurable and quantifiable information, including a patient’s vital signs, notes from the doctor’s physical exam, allergies, and reports from diagnostic tests, such as blood tests and imaging.

Assessment

This is the physician’s analysis and includes the diagnoses, patient progress, and evaluation of medication or treatment. It’s generally a summary statement, and should not repeat information in the Subjective and Objective sections.

Plan

This is the treatment plan for the patient’s condition, such as medications, additional procedures and diagnostic tests (if needed), referrals, goals, and follow-up steps. It’s not needed to rewrite a previous treatment plan, but it’s critical to include changes to an existing plan.

The ABC's of SOAP Notes for Practices

SOAP refers to Subjective, Objective, Assessment, and Plan—a standardized method of documenting patient encounters. The purpose of SOAP notes is to provide a roadmap to concisely record patient information efficiently and accurately. The notetaking method also makes it easier to share patient information between clinicians in a way that minimizes confusion and misinterpretation.

There are four parts to a SOAP note:

Subjective

This is the patient’s complaint—what brings them to a physician’s office. It includes symptoms, when they started, the frequency and severity of the symptoms, the region of the body affected, and other relevant information such as family history, social history, and past and present illnesses.

Objective

This section represents measurable and quantifiable information, including a patient’s vital signs, notes from the doctor’s physical exam, allergies, and reports from diagnostic tests, such as blood tests and imaging.

Assessment

This is the physician’s analysis and includes the diagnoses, patient progress, and evaluation of medication or treatment. It’s generally a summary statement, and should not repeat information in the Subjective and Objective sections.

Plan

This is the treatment plan for the patient’s condition, such as medications, additional procedures and diagnostic tests (if needed), referrals, goals, and follow-up steps. It’s not needed to rewrite a previous treatment plan, but it’s critical to include changes to an existing plan.

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  • Interoperability & Productivity

    Consistent documentation enhances communication.

  • Risk Reduction

    Lower risk of mistakes and malpractice claims.

  • Efficiency & Simplicity

    A standardized template simplifies charting.

Interoperability & Productivity

With more healthcare software interoperability on the horizon, SOAP notes make it easier to share patient information across multiple Electronic Health Records (EHR) platforms and providers. Consistent documentation enhances provider-to-provider communication, reduces redundant tests and imaging, and enhances health outcomes.

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Risk Reduction

With a prescribed approach to documentation, there is a lower risk of mistakes that can lead to malpractice claims. For example, SOAP notes can help minimize medical record errors that have resulted in 37% of high-severity injury cases in the past.

Interested in learning more about reducing practice risk? Check out RXNT’s Risk Awareness toolkit packed with resources to help practitioners identify risks and proactively address them.

Efficiency & Simplicity

Healthcare providers and practices, small and large, have a lot to manage and even minor distractions and miscommunications can lead to costly mistakes and missed information. A standardized template simplifies charting and boosts the time available for patient interactions.

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Customizable Smart Forms for SOAP Notes

RXNT offers customizable Smart Forms for Electronic Health Records that help you tailor encounters and documentation to your practice. Hundreds of forms are available, including a Basic and a Detailed SOAP form with separate “plug-ins” for Vitals, Allergies, Medications, and Orders. Plus, reduce clicks with Short Keys and Procedure Macros that allow you to quickly add commonly-used text blocks to your encounter templates. 

"Very intuitive. Easy to navigate. Much more user friendly than competing programs."
Gabrielle

"There are such a significant number of advantages, I don't know where to begin! The staff at RXNT is awesome."
Federico

"Great value, integrated system. Have used daily for years and keeps getting better"
Mike

RXNT has been a great experience for our office. Our providers say that it is the easiest they have found when it comes to charting progress notes.

Melinda
Adrian Counseling & Psychiatric Clinic

The best customer service I've seen in the [industry]. From the beginning, all the staff at RXNT has been extremely helpful and knowledgeable.

Alejandra
Greenwich Psych, PC

See our SOAP note template in action!

Get an easy, virtual demo to learn more about SOAP notes or to see how RXNT's other customizable templates will help create efficiencies and streamline your practice. Our friendly, no-pressure customer advisors will answer any questions and help you to evaluate your needs.

Used in healthcare organizations of all sizes, from small family clinics to large, multi-specialty practices—we offer flexible pricing options to make our tools accessible to almost any practice. Every product is backed by 24/7 cloud-based access, premium in-house support, and regular system upgrades.

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