How to Read a SOAP Note

SOAP notes are documentation written by healthcare professionals. The acronym stands for: subjective, objective, assessment and plan for a patient. There are standards that must be adhered to in order for the notes to be consistent throughout the medical field. If you are familiar with medical terminology, you should be able to read SOAP notes and understand the patient diagnosis as well as the recommended treatment plan.

Things You'll Need

• Medical terminology dictionary
• SOAP notes

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Instructions

• 1

  Read the subjective notations. This portion of the note outlines the purpose for the doctor's visit. This is also where the patient's medical history is recorded, as well as additional observations. For example, the subjective portion of the note may describe the patient as "appears lethargic." The subjective section also includes information that has been learned from the patient or the patient's caregiver. An example of this would be, "Bob Smith is a 38-year-old healthy male complaining of back pain. He has used over-the-counter pain relievers but the pain has persisted."

• 2

  Review the objective portion. Physicians make objective notations regarding their discoveries during the examination. Objective notes include information such as a rash or other visible signs of illness. The notes on the objective portion will also list results of the physical examination, including vital signs such as the patient's temperature, blood pressure, heart rate, weight and body mass index. Diagnostic test results go in this section; this can include laboratory results, pathology reports and imaging.

• 3

  Look at the assessment for information about the patient's diagnosis. It is possible for several diagnoses to be listed in the assessment. The list of possible diagnoses is typically written in order of most likely to least likely.

• 4

  Review the plan. The plan outlines the recommended treatment for the patient. The plan will include any medications that will be prescribed, physical therapy and recommended lifestyle changes. The plan is the area of the SOAP note used for communication between clinicians. The plan must be well-organized and fully outline the treatments.