SOAP notes, written clearly.

A SOAP note is a way of writing up a single patient encounter — visit, session, or admission — using four short headings, always in the same order: Subjective, Objective, Assessment, Plan.

It is the most widely used clinical note format in the world. Doctors use it. Nurses use it. Therapists, counsellors, physios, dentists, pharmacists, paramedics, dietitians — almost any health worker who documents a patient encounter has written a SOAP note at some point in their training, even if they don’t call it that any more.

Each letter answers a different question. Together, they take the messy reality of a consultation and shape it into something another clinician — or your future self — can read in thirty seconds and act on safely.

• S — Subjective. What the patient tells you.
• O — Objective. What you observe and measure.
• A — Assessment. What you think is going on.
• P — Plan.What you’re going to do about it.

The order is not decorative. It mirrors how clinical thinking actually moves: listen first, examine, reason, act. A note that follows that path is easier to write, easier to read, and — when something goes wrong — easier to defend.

SOAP was invented in the late 1960s by an American physician named Lawrence Weed. Weed was frustrated by the medical records of his time — page after page of unstructured prose where the clinician’s reasoning was buried, if it appeared at all. A diagnosis would sit in a note without any sign of how it had been reached, which left every doctor reading it later guessing.

His answer was the problem-oriented medical record: organise each note around the patient’s active problems, and for each problem write down, in order, what the patient said, what you found, what you thought, and what you planned to do. He called those four headings SOAP.

“The medical record should be a working tool — one that makes the clinician’s thinking visible, not just their conclusions.”
— paraphrased from Lawrence Weed, Medical Records, Medical Education and Patient Care, 1969

Sixty years later, the format has outlived almost every other documentation fashion. The reason is simple: it makes you show your working. A SOAP note is harder to bluff than a narrative paragraph.

The Subjective section is the patient’s story, in their frame. It is everything you cannot measure: what they feel, how it started, what makes it better or worse, what they’ve already tried, what they’re worried about, and what they want from this visit.

A useful Subjective answers four quiet questions that a colleague reading the note an hour later will ask:

• What brought them in?The presenting complaint, in one short sentence — ideally close to the patient’s own words.
• How did it unfold? Onset, duration, character, radiation, associated symptoms, aggravating and relieving factors. The classic history-taking spine.
• What context matters?Past illnesses, medications, allergies, family and social history — but only the parts that actually bear on today’s problem.
• What does the patient want? Reassurance, a prescription, a referral, an explanation. Their goals shape your Plan.

Notice what changed. The second version takes the same information and turns it into something the next clinician — or you, on Thursday — can use to think. Two extra sentences. No jargon. No fluff.

What doesn’t belong here

Your physical examination findings, your differential diagnosis and your management plan. Subjective is what the patient said and what they brought to the room. If you find yourself writing “tender on palpation” in Subjective, move it down to Objective. If you find yourself writing “likely viral”, move it down to Assessment.

Objective is your half of the encounter. It holds anything you gathered with your own senses or your tools: vital signs, examination findings, point-of-care tests, results that are back from the lab, relevant images.

The discipline of this section is to state findings as findings, without interpreting them. “Chest clear to auscultation” belongs in Objective. “No evidence of pneumonia” belongs in Assessment — that is already a conclusion. Keeping the two separate is what allows a different clinician to reread the note and form their own opinion.

A reliable order

1. Vitals first. Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, weight if relevant. One compact line.
2. General appearance. Alert, comfortable, in pain, distressed. A single sentence.
3. Focused examination by system. Only the systems you actually examined. Empty checkbox lists from a template should either be filled honestly or removed.
4. Investigations available today. Point-of-care tests, recent labs you reviewed, imaging.

The most common Objective mistake

Writing what you usually do, not what you actually did today. A complete cardiovascular and respiratory examination on a patient who came in with an ankle sprain is not impressive — it’s a record nobody believes. Write what happened.

Assessment is where your clinical reasoning becomes visible. Out of everything you heard in Subjective and saw in Objective, what do you now believe? And — just as important — what are you ruling out?

A strong Assessment usually has three parts:

1. A working diagnosis, named in one line. Even if you’re uncertain, commit to your best current explanation.
2. The reasoning behind it, in one or two sentences. What in the history and exam points this way? What argues against it?
3. A differential, in rough order of likelihood, with a brief note on what you would do to confirm or exclude each.

It does not need to be long. Three sentences can be enough. What it cannot do is skip the reasoning. A note that says only “tonsillitis” tells the next clinician your conclusion but not how you got there — and if you turn out to be wrong, there is no trail to follow back.

Differential vs working diagnosis

A differential lists the conditions you are considering. A working diagnosis is the one you are acting on right now. Both belong here. Naming a differential is not a sign of indecision — it is a sign you are thinking. It is also what lets you safely review the patient later: you already know what to look out for if the picture changes.

One short rule

If the Plan would change depending on the answer to a question, that question belongs in the Assessment. Pull it out of your head and put it on the page.

Plan is the most operational section, and the one that protects patients most directly. It is everything that follows from the Assessment: what you ordered, what you started, what you stopped, what you told the patient, when you’ll see them again, and what should bring them back sooner.

The clearest Plans split into five small buckets. Not every visit needs all of them — but it’s worth running through them as a mental checklist.

1. Investigations.What you ordered, and why. If you didn’t order something a reader might expect, a one-line reason is generous.
2. Treatment. Medications started, dose, route, frequency, duration. Procedures done. Treatments stopped — and why you stopped them.
3. Education and shared decisions. What you discussed with the patient, what they chose, what they agreed to. This is what turns a clinical decision into informed consent.
4. Safety-net. The specific symptoms that should bring them back urgently, where to go, and by when. The single most missed item in real-world notes.
5. Follow-up.When you’ll review them, with whom, and what you’ll be checking. “Review in two weeks” is fine. “Review if needed” rarely is.

One thing worth being strict about

Every Plan item is better with an owner and a timeframe. “Send for ECG” becomes “ECG today in clinic, reviewed by me before patient leaves”. “Refer cardiology” becomes “Refer cardiology — letter sent today, expected appointment within 6 weeks”. The extra words are what turn intent into action.

The clearest way to feel the format is to read a complete note. The case is fictional. Every line is the kind of line we actually look for when reviewing a chart.

SOAP is a shape, not a script. The four sections mean roughly the same thing wherever you use them, but the content shifts to match the work. A few sketches.

Therapists in particular often choose a related format — DAP or BIRP— that compresses Subjective and Objective into a single “Data” line. That’s fine. The thinking is identical; only the headings change.

The format is simple. The pitfalls are predictable. A short tour of the seven we see most often, with the small move that fixes each one.

1. 1

   Subjective that says nothing

   “Pain. Worse today.” A note that thin tells the next clinician what the patient looked like, but nothing about what they said. A useful Subjective always names at least one specific symptom, its character, and how it’s changing.

2. 2

   Mixing Objective with Assessment

   Writing “no evidence of pneumonia” in Objective is already a conclusion. Findings go in Objective, conclusions go in Assessment. Keeping them separate is what lets a different clinician reread the note and form their own view.

3. 3

   A Plan with no owner and no timeframe

   “Refer cardiology” on its own is a wish. “Refer cardiology — letter sent today, expected appointment within 6 weeks” is a plan. Add the verb, the actor, and the when.

4. 4

   Forgetting the safety-net

   The single most missed item in real-world Plans is the safety-net: the specific symptoms that should bring the patient back urgently, where to go, and by when. It’s a two-line addition that protects the patient — and you.

5. 5

   Copy-forward decay

   Copying a previous SOAP note across and editing “a bit” is how stale findings sneak into the chart for months. If you copy forward, re-examine every section, not just the new one.

6. 6

   Writing for nobody in particular

   A SOAP note has two readers: the next clinician seeing this patient, and a future version of you reviewing the case. Write so both can pick it up cold. Avoid in-jokes, avoid invented abbreviations, define anything specialty-specific the first time it appears.

7. 7

   Length as a proxy for care

   A long note is not a careful note. A short, well-structured SOAP note that names a working diagnosis and a clear plan is worth more than two pages of unedited narrative. Aim for clear, not exhaustive.

SOAP is not the only format, and it is not always the best one. A quick map of the alternatives most clinicians will run into, and when each makes sense.

If your workplace doesn’t mandate a format, the question to ask is not “which is best?” but “which one will I actually write consistently for every patient?”. A SOAP note you write every time beats a BIRP note you write half the time.

Copy this into your EHR, your text editor, or your favourite notes app. The prompts under each heading are the fields most often left out of real-world notes — leave them in and the chart will be easier on you and on whoever reads it next.

SUBJECTIVE
- Presenting complaint and duration:
- History of presenting complaint (onset, character, associated symptoms, what helps / worsens):
- Relevant past medical, surgical, drug, allergy, social, family history:
- Patient's own concerns and goals for the visit:

OBJECTIVE
- Vitals: T · HR · BP · RR · SpO2 · weight
- General appearance:
- Focused examination by system:
- Investigations available today (point-of-care, recent labs, imaging):

ASSESSMENT
- Working diagnosis (one line):
- Reasoning (what supports it, what argues against, what you're excluding):
- Differential, in order of likelihood:

PLAN
1. Investigations ordered (and why):
2. Treatment started or adjusted:
3. Patient education and shared decisions:
4. Safety-net (when to come back urgently):
5. Follow-up (when, with whom, what to review):

Most modern AI scribes — including ours — produce notes in the SOAP format by default. The reason is the same reason the format has lasted: it’s the clearest way to take a recorded conversation and turn it into something a clinician can read in under a minute.

The workflow is consistent across tools:

1. Listen. The visit is recorded — with consent — either continuously or on tap.
2. Transcribe. Speech is converted to text, usually with speaker labels for the clinician and the patient.
3. Structure. A language model sorts the transcript into the four sections: what the patient said becomes Subjective, what the clinician observed becomes Objective, the reasoning becomes Assessment, the next steps become Plan.
4. Review. The clinician reads the draft, adjusts, and signs off. The note is theirs.

Two honest caveats. AI scribes are very good at structure and very bad at the things they didn’t hear — silent examination findings, your private clinical reasoning, the safety-net you delivered with your eyes. Anything that wasn’t spoken aloud will not appear in the draft unless you add it. And every AI scribe will occasionally invent a detail that sounds plausible but isn’t there. The review step is not optional.

Used well, an AI scribe takes a clinician’s documentation time from a quarter of their day to a few minutes per patient. Used badly, it puts confident-sounding errors into a chart. The format doesn’t care which one you do — but your patients do.