How to Write a Soap Note Assessment

A SOAP note is a method of documentation used by health-care professionals. SOAP is an acronym: S stands for subjective, O for objective, A for assessment and P for plan. The SOAP note is documented in the patient's chart; it is a standardized form of documentation and explains the patient's interactions and progress. SOAP notes are a popular format for health-care documentation and are used across the spectrum of health-care services.

Things You'll Need

• Patient chart
• Pen

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Instructions

• 1

  Document in the note a patient statement or what the patient observes. The "S" in SOAP stands for subjective, so this part of the documentation is related to the patient's observations of her own symptoms or a complaint about some ailment. It is generally reported in the patient's words.

• 2

  Document in the note what you see and observe about the patient. The "O" stands for objective, so this is what the health-care provider perceives. This part of the documentation can agree with the subjective part of the note or it might be different.

• 3

  Write how the patient is progressing. The "A" stands for assessment, so this part of the note is a review of how the plan for the patient's progress is working. It can be detailed or brief, depending on the patient's diagnosis, plan of care and other considerations. It can be written as a short statement or in an outline format, detailing the pieces of the care plan that are beneficial. The assessment can also document whether or not care goals have been achieved.

• 4

  Document revisions and additions to the plan. The plan for the patient is ongoing and will require revision as the patient progresses or as the patient's condition changes. This section---"P" for plan---documents changes, additions and revisions. It can be short or detailed and outlines continued and ongoing goals for the patient. It might also list some long-term goals. If some care goals are met, this part of the note will indicate what they are.