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SOAP Notes Guide

Subjective, Objective, Assessment, Plan — the cornerstone of structured clinical documentation.

What Are SOAP Notes?

SOAP notes are a structured method of clinical documentation developed by Dr Lawrence Weed in the 1960s. They organise clinical information into four logical sections that mirror the clinical reasoning process.

S — Subjective

What the patient tells you. This includes the presenting complaint (ideally in the patient's own words), history of presenting complaint, relevant past history, medications, allergies, social and family history. It also includes information from carers, relatives or other informants — note the source.

O — Objective

What you observe and measure. This includes vital signs and early warning scores, physical examination findings, investigation results (blood tests, imaging, ECG), and observations from other members of the clinical team. Objective data is measurable and reproducible.

A — Assessment

Your clinical interpretation of the subjective and objective data. This includes your primary diagnosis, differential diagnoses in order of likelihood, and your reasoning. Document your clinical impression clearly — this section demonstrates your clinical thinking.

P — Plan

What you are going to do. List specific, actionable steps for each active problem. Include investigations, treatments, referrals, monitoring, escalation criteria, discharge planning and follow-up. A good plan is numbered, specific and assigned to a responsible clinician.

Tip: Some clinicians add E (Evaluation) for follow-up entries, creating SOAPE notes — documenting the patient's response to treatment.
SOAP Template 
SOAP NOTE
=====================================
DATE: ___________  TIME: ___________
CLINICIAN: _____________________________

PATIENT: ______________________________
DOB: _____________

S — SUBJECTIVE
-------------------------------------------
Presenting complaint:
[In patient's own words]

HPC:
[Onset, duration, character,
 severity, associations,
 relieving/aggravating factors]

PMH / PSH:
Medications:
Allergies:
Social history:

O — OBJECTIVE
-------------------------------------------
Vital signs:
HR: ___  BP: ___/___  RR: ___
Temp: ___  SpO2: ___
Score (NEWS/PEWS): ___

Examination:
[Findings by system]

Investigations:
[Relevant results]

A — ASSESSMENT
-------------------------------------------
Primary diagnosis:
[Your clinical impression]

Differential diagnoses:
1.
2.
3.

P — PLAN
-------------------------------------------
1. [Specific action - by whom]
2.
3.

Monitoring:
Escalation if:
Follow-up:

SIGNATURE: ____________  DATE: _________
NAME (print): __________________________