The Subjective section of your soap note is about what the patient is experiencing and how they are handling their concerns. Some common examples may include chest pain, decreased appetite, and shortness of breath. You can also talk to a family member or spouse to get any necessary information.

Onset: when did the CC start? Location: where is the CC? Duration: how long has the patient been affected by the CC? Characterization: how does the patient describe the CC? Alleviating or Aggravating factors: does anything make the CC feel better or worse? Radiation: is the CC in a single location or does it move? Temporal patterns: Does the CC occur at specific periods of time? Severity: On a scale of 1-10, with 10 being the worst, how does the CC feel?

Only write down the details that are important to your current patient. Don’t include full medical histories for relatives if they aren’t relevant.

For example, you may write: Ibuprofen 200mg orally every 6 hours for 3 days.

The Objective section of the SOAP note refers to data that you collect and measure from the patient.

For example, instead of writing, “stomach pain,” you would write something like, “abdominal tenderness when pressure applied. ”

Include printouts of any lab data or photos from the lab tests so other medical professionals can see them first hand.

For example, if you had previously prescribed an antibiotic, you may record how the affected area has less swelling.

You may not know exactly what’s causing the problems, so make educated guesses based on what you’ve already found.

Always leave a description so other professionals know why you made certain decisions with your treatment.

For example, you may need to perform an X-ray or CT scan to determine if there are more causes for underlying pain. List what should be done after special tests whether they come back positive or negative.

Sometimes, you may need to perform surgery depending on the severity of the concern.

For example, you may write, “45-year-old female presenting with abdominal pain,” as the first step in your SOAP note.

There is no required format or length for the content in your SOAP note as long as it follows the Subjective-Objective-Assessment-Plan order.