Mastering SOAP Notes as a Health Professional

SOAP notes are a trusted method of documentation in the field of healthcare. They offer medical professionals a comprehensive and consistent method for capturing the details of a client session. They’re highly effective, too, when you consider SOAP notes have been providing a cognitive framework for clinical reasoning in traditional medicine for decades.

If you’re a health and wellness pro wondering what is the benefit of using SOAP notes in building your functional medicine practice, it turns out there are many: 

• SOAP notes ensure a client’s relevant health status information is documented in a standardized format.
• SOAP notes provide an ongoing documentation tool to manage a client’s care, make evidence-based decisions, and continuously tailor treatment plans to address evolving needs on an individual’s health and wellness journey.
• SOAP notes represent a legal document that licensed professionals can submit in court proceedings related to insurance claims and disputes, workplace accidents, and more. It’s yet another way to safely future-proof your practice.

It may be tempting to think that they're called “SOAP notes” because they clean up your documentation (and, spoiler, they do). SOAP is actually an acronym that stands for Subjective, Objective, Assessment, and Plan. Each of these words represents a unique section of notes you take during a client encounter. 

In this article we’ll dive into each individual SOAP component, provide details on how to write a SOAP note, and share some relevant examples of SOAP notes for health and wellness professionals.

If you're looking to spend more time on your clients, and less on your notes, check out AI Charting Assistant, a suite of tools designed to increase your note-taking efficiency.

How to write a SOAP note

A best practice for how to write a SOAP note is to assume that someone else will be reading it. Even if you end up being the only one who has eyes on your SOAP note, this mindset will encourage you to use clear language that’s easy for a client, colleague, or even litigators to understand. You should also strive for objectivity, sticking to the facts and avoiding assumptions or judgments.

When to use a long SOAP note

Depending on your clinical needs, your SOAP note template can be short or long. Long SOAP notes provide a more comprehensive summary, in-depth explanations, and detailed treatment plans. An example of a SOAP note a practitioner might create when meeting a client for an initial evaluation around chronic digestive issues would likely choose a longer format that captures this type of information:

• A detailed account of the client’s reported experiences and symptoms – like pain, bloating, and constipation – how often they occur and their perceived level of discomfort (Subjective)
• The practitioner’s long-form observations around the client’s emotional and physical state (Objective)
• The practitioner’s diagnosis of suspected gut dysbiosis and chronic inflammation (Assessment)
• Details around any tests the practitioner wants to run, their plans to prescribe a probiotic regimen based on results, their recommendations around transitioning to a gut-healing diet, and any lifestyle factors the practitioner wants to recommend (Plan)

When to use a short SOAP note

Using a short SOAP note template would be more appropriate for instances where a brief overview of the patient’s status will suffice, like during a follow-up visit or routine check-in. In our example above, the practitioner would likely take shorter SOAP notes if the client’s gut health has greatly improved and the appointment is a quick check-in on progress. 

Elements of a SOAP note: Subjective, Objective, Assessment, and Plan

Let’s now dive a little deeper into the four components of SOAP notes – Subjective, Objective, Assessment, and Plan.

Subjective: How do they feel? 

The Subjective section of your SOAP note is where you capture detailed information about your client’s complaints and experience of their symptoms. It typically centers around a Chief Complaint (CC), which is the thing that motivated them to book an appointment with you. You should avoid making assumptions about how a client is feeling or adding your own opinions and interpretations. Including direct quotes from your client can also help to keep your SOAP note unbiased and focused on the client’s point of view.

A SOAP note example: Meet Claire

To help put this into perspective, let’s look through the lens of an ND whose practice centers around helping women navigate perimenopausal hormone shifts and live their most balanced lives through this natural life transition. This practitioner is meeting with a new client, 48-year-old Claire, who is complaining of crashing fatigue, night sweats, sleep disturbances, and stubborn belly fat. Here’s a Subjective SOAP note example that outlines the types of information this practitioner might document:

• Chief Complaint. This practitioner will capture the symptoms that Claire reports are causing her the most grief. For example, Claire may share that she feels tired constantly and lacks energy for the activities that used to be an easy part of her everyday experience. Claire may also share that she is dealing with intense episodes of sweating during the night, which is disrupting her sleep, or that she struggles to fall asleep and/or stay asleep.
• There’s an opportunity to capture sound bites directly from Claire here as well.  e.g., “My fatigue feels as intense as it did when I had my newborn babies to care for. It’s an unrelenting level of tiredness that’s impacting my work, social life, and happiness.”
• Here are some other areas this ND could investigate to include in her SOAP note:
  • Fatigue symptoms onset and change over time
  • Whether anything Claire does improves the symptoms 
  • Details on Claire’s menstrual cycle – length, heavy flow, pain, and other factors 
  • Any medications or supplements currently taken 
  • Factors like lifestyle, diet, exercise, and self-care 
  • Stress events or factors impacting day-to-day life
  • Family history of menopause or other significant medical conditions
  • Any other health-related issues or symptoms in play

Objective: What does the data say?

The Objective section in your SOAP note is where you capture quantifiable data obtained during your assessment. This is where you record things like lab results, physical examination findings, vitals, and your own observations from interacting with the client. In this section of your SOAP note, you’re focusing on facts and observations that haven’t been through the subjective lens of the client.

Returning to our fictional client Claire, some Objective SOAP notes examples her practitioner could document include:

• General appearance or mood. (For example, "Claire appears tired, with visible dark circles under her eyes. She yawned continuously throughout our session")
• Vital signs, including blood pressure and temperature
• Physical examination findings, like observations related to abdominal bloating
• Lab test results. For example, if our ND had the client perform a DUTCH test (Dried Urine Test for Comprehensive Hormones) prior to the first consult, she would include the results in her Objective SOAP note. 
• Relevant medical records. For example, if Claire approached her primary care provider for symptom resolution first, she could have blood work results to share that document things like Vitamin D levels or inflammation markers.

Assessment: What’s your evaluation of the situation?

In the Assessment section, you'll use the information gathered in the Subjective and Objective stages to form your professional diagnosis. In the US, if a client comes to you via referral from a primary care provider, they should share an ICD-10 diagnosis code that you can also consider to inform your assessment.

The Assessment section of your SOAP notes is also the place to document client progress or changes in subsequent client sessions. It’s a crucial space for documenting your thought processes and the reasoning behind the treatment plan you prescribe.

If we go back to Claire’s SOAP note Assessment example, this is where her ND would outline what she believes is the root cause of the troublesome symptoms:

• Based on Claire's reported symptoms of crashing fatigue, night sweats, and sleep disturbances, in combination with the DUTCH test results showing fluctuations in estrogen and progesterone metabolites, there is strong evidence of hormonal imbalance related to perimenopausal transition.
• Analysis of Claire's dietary intake reveals potential nutritional deficiencies, particularly in essential vitamins and minerals that play a role in hormone regulation and overall health.
• Claire's busy lifestyle and difficulty managing stress may be elevating her cortisol and exacerbating her symptoms.

Plan: What are the next steps?

The Plan section of your SOAP notes is where you put care into action. It outlines your recommended treatment plan tailored to the root causes of a client’s symptoms and designed to support overall well-being. Some of the details it could cover include:

• Supplements prescribed, including frequency and duration 
• Recommended lifestyle or dietary changes
• Frequency and duration of recommended protocols
• Any further testing or assessments you’ve prescribed
• Referrals to other practitioners or experts 
• Follow-up plans and related dates

Finishing up with our fictional practitioner who is treating Claire for perimenopausal fatigue and more, her Plan SOAP note examples would include the following:

• Details of a hormone-balancing protocol featuring targeted botanicals to address specific hormone issues, including adaptogenic herbs for adrenal support
• Recommending an anti-inflammatory diet rich in fruits, vegetables, omega-3 fatty acids, and antioxidants to reduce inflammation
• Supplements prescribed, including vitamin D to address a found deficiency, Omega-3 to modulate inflammatory prostaglandins, and magnesium to aid with anxiety and sleep
• Referral to a lifestyle coach for additional stress reduction, self-care, and sleep hygiene work 
• Follow-up and monitoring includes ongoing tracking of sleep through Apple Health integration and bi-weekly 1:1 check-ins for the first two months. Determine when to repeat DUTCH testing after this period based on Clarie’s progress and response to the treatment plan. Adjust the treatment plan as needed during this time.

Increasing your SOAP note efficiency

Imagine a world where you can listen intently to and empathize with your patient in front of you instead of staring at your keyboard. Or better still, imagine a world where you finish your charts during or shortly after your session.

Thanks to AI, that dream is now a reality.

You can use AI Charting Assistant to generate SOAP notes in two ways:

• AI Summary writes out notes in your format of choice, including SOAP notes, generated from your telehealth appointment in Practice Better.
• AI Dictation transcribes your speech into notes in real time, allowing you to watch your notes take themselves.

Whichever method works best for your practice, you can quickly generate a SOAP note from your session and get back to what matters: patient care.

If you're a Practice Better customer, you can try AI Charting Assistant free, the first 600 minutes are complimentary.

Try AI Charting Assistant for yourself and save valuable time to reinvest in patient care or keep building your dream practice.

Using SOAP Notes with Practice Better

All Practice Better plans include pre-built note templates, including a SOAP note template. Practice Better customers simplify the process of documenting their client sessions and progress.

A sample SOAP note on mobile view using the Practice Better app

Practice smart charting with SOAP notes

We’ve outlined quite a few SOAP notes examples in this article. The truth is, no matter how you choose to incorporate SOAP notes, they are a fantastic way to provide personalized, client-centric care combined with evidence-based decision-making that makes a positive impact on every client’s health and wellness.

Try out AI Charting Assistant and start focusing on your clients, not on your notes. The first 600 minutes are free.

[Editor's note: this post was originally posted on August 22, 2023. It has been updated for comprehensiveness and accuracy.]