Many clinicians rely on formats and templates to help ensure that they document everything that they need to. Standardised and structured ways of writing notes also take some of the cognitive load off documentation.

One of the most used and taught formats for note-taking is ‘SOAP’, which originated in the 1960s. Let's take a whistle stop tour of SOAP notes and what to include in yours.

What are SOAP notes?

SOAP is an acronym for the different sections clinicians need to document:

• Subjective - the patient’s main complaint or reason for seeking care
• Objective - the clinical professional’s observations or examinations
• Assessment - the professional’s record of any diagnoses
• Plan - a record of any suggested or discussed treatment, as it relates to the reason for seeking care

Why has the SOAP format become so widespread?

There are several reasons for the SOAP note's enduring popularity with clinicians:

• It introduces a standardised order and structure to clinical notes. You should know which section to look at to find the information you're looking for.
• It acts as a cognitive framework for clinical reasoning. Each section guides you through the process of assessing, diagnosing, and treating a client.
• It reduces, at least in theory, the need for clinicians to spend a long time on their notes. The format instead focuses them on what is important to document.
• SOAP notes can be used when writing on paper or electronically. Now, most clinical records are electronically created and stored, which is necessary as the amount of data collected has increased.

Keeping detailed and organised notes when dealing with patient care is critical. SOAP notes should create a consistent and unbiased record for even the most complex issues.

Not only that, but this framework links the treatment plan to the reason for seeking care. That should mean that anyone who reads the notes can clearly understand the rationale and relevance of care provided to that patient. Understandably, that means that SOAP notes are required for insurance claims in certain countries.

Who uses SOAP Notes?

Any professional treating some kind of patient or client can use the SOAP format for their notes. It is often used by:

• Medical doctors
• Dentists
• Psychologists
• Nurses
• Emergency medical technicians
• Veterinary practitioners

The use of the SOAP framework varies by profession and country. For example, it's not common in the United Kingdom but it is often used in the United States.

Regardless, it’s still the most prevalent of all the different clinical note-taking frameworks around (and there are quite a few!).

Clinical significance of SOAP

Medical documentation serves many needs. As a result, medical notes have expanded in both length and breadth compared to fifty years ago. Now, 60% of documentation happens online.

This has unintended consequences - it makes it easy to incorporate large volumes of data. These long notes and records risk burdening a busy clinician if the information is not useful. Patients may also come to harm if records are hard to comprehend or inaccurate.

The most clinically relevant data needs to be easy to find quickly.

The advantage of a SOAP note is the way in which you organise information. The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow. Each section should be clearly labelled, short and to the point.

Another healthcare professional should be able to pick up where you are in the course of treatment at a glance.

But there's a fine balance between brevity and comprehensiveness that isn't defined when it comes to writing SOAP notes. Many professionals wonder how best to document these notes and what to put in each section.

So, let’s dive into writing SOAP notes and we think what good looks like.

How to write SOAP notes

The simplicity of SOAP notes is that you can write them on any medium. They are also flexible enough that you can adapt the four sections to include sub-sections. The goal is to make your notes easy to comprehend within the SOAP structure.

The 4 Cs of good record-keeping also apply here: comprehensive, clear, concise and contemporaneous.

One things to be aware of is that there's no pre-defined formatting for SOAP notes. Many SOAP notes are written continuously as prose, per section. In Kiroku, we break them out for improved legibility.

Subjective = Complaint & Context

This section provides context for your clinical record. Everything you do in the following sections must relate back to what you have recorded here.

What you document must relate to the experiences, personal views or feelings of your patient or someone close to them. In effect, this is the patient’s history and reason for presenting.

Start your SOAP note with the chief complaint (CC) or presenting problem. This is a simple one-line opening statement detailing the reason for their visit.

Document the chief complaint

Don’t include anything that can be perceived as passing judgement or irrelevant to the patient and their symptoms. You must document the patient’s perceptions in an unbiased and matter-of-fact way.

It’s best to use the patient’s own words. If not from the patient directly, state who the information came from and their relationship to the patient.

For thorough notes, ask the patient to elaborate on their chief complaint and history (use the OLDCARTS acronym):

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterisation: How does the patient describe the CC?
• Alleviating / aggravating factors: What makes the CC better or worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 (least) to 10 (most), how does the patient rate the CC?

Gather relevant histories

Document past medical or surgical information, family histories and medications if relevant. For medication, document the name, dose, route, and how often it should be and is being taken (adherence).

You can follow the established HEADSS assessment guide to screen for social factors. This might be more relevant for children, young adults, or even elderly patients.

Finally, it’s good practice to run a Review of Systems (ROS). These questions help uncover symptoms not otherwise mentioned by the patient, such as:

• General e.g. weight loss, decreased appetite
• Gastrointestinal e.g abdominal pain, hematochezia
• Musculoskeletal e.g. swelling, pain, decreased range of motion

The information in the S section of your notes will be relied upon in the future. Make sure to include any lack of symptoms as well as presenting symptoms, if relevant.

Focus on relevance and quality

Use your clinical judgement, expertise and decision-making skills to ask and record information. When starting to write clinical records, focus on the quality and clarity of your notes.

There is a lot to document in the subjective section of your notes. Many clinicians use abbreviations to minimise the amount they need to write and speed up the note-taking process. This can make notes difficult to read as not everyone uses the same abbreviations.

As there's so much to document, it's common to use a template or note-taking tool, such as Kiroku. This helps you to document essential information without worry that you might have missed something out.

Objective = Observations

In this section, you need to record observable, quantifiable, and measurable data. This could include:

• Patient behaviours
• Mental status
• Vital signs or physical examination findings
• Tests carried out and their results (lab, imaging or diagnostic)
• Treatments applied or carried out
• Patient responses to any procedures, including readings

Don't fall into the common mistake made in this section:

• Symptoms are subjective descriptions (patient stating they have stomach pain).
• Signs are objective findings associated with the reported symptom (abdominal tenderness to palpation)

Refrain from including any general statements without supporting data. Don't write personal judgements, assumptions or information open to personal interpretation.

Avoid words such as these when describing your patient:

• Uncooperative
• Obnoxious
• Normal
• Drunk

Assessment = Diagnosis

This section connects the dots between “subjective” and “objective” evidence to arrive at a diagnosis. Your role is to analyse the problem, the factors impacting the patient, and changes that you observed.

Note decisions or changes to the client’s diagnosis or treatment plan here. This section is the evidence of your role in the patient's healthcare journey, as it relates to this episode of care. Remember that you are one of many clinicians likely to care for this patient throughout their life.

If a patient's complaint is recurring, don't dismiss this as already documented in their record. It will allow future clinicians to understand and spot patterns or evolutions.

If you're using some form of clinical-note-taking software, like Kiroku, you might find that parts of your assessment information are already filled out for you. This is because of the smart links that are built into Kiroku's technology.

Kiroku takes information already provided and helps you to write faster, standardised and more personalised notes with minimal effort. Instead of typing, your notes are primarily populated through clicking.

Where a patient may have more than one diagnosis or problem, list them in order of importance. You should also note down the differential diagnosis, a list of the different possible diagnoses, again in order of likelihood.

Explain the thought process behind your list of diagnoses and reasons for excluding (or lessening) certain diagnoses. You might frame it something like this: [Problem], [Differential Diagnoses], [Discussion]. Repeat for any other diagnoses.

Avoid repeating previous statements in the S and O sections. This section should be a problem-oriented medical record. Focus on the progress, regression, or plateau of the patient’s progress.

Plan = Immediate next steps

To wrap up the note, write what’s next for the patient’s treatment. "Plan" is for immediate next steps, and how those steps will move the patient closer to anticipated goals.

You can detail the need for additional testing and consultation with other clinicians to address the patient's illnesses. You can also address any additional steps being taken to treat the patient. It helps future clinicians understand what needs to be done next.

For each problem:

• Note any necessary tests and how they resolve diagnostic ambiguities
• State the next steps for the different test outcomes
• Note nutritional, physical, and medical attributes (medications) that will contribute to the patient’s therapeutic goals.
• Document specialist referral(s) or consults and any patient education or counselling needed.
• Note any progression or regression the patient has made in treatment.

Common SOAP note mistakes

Because SOAP notes cover so much information and rely on your clinical judgement, there are some common mistakes that tend to occur.

These tend to fall into common themes relating to:

• Language - using vague language, writing opinions in the subjective section
• Repetition - for example, adding to the Plan section information covered in the Assessment section
• Judgement - not including the right level of information based on the patient’s chief complaint
• Missing information - not including ‘normal’ information or tests

Tools for writing SOAP notes

As you’ve seen, there’s a lot that you need to include in your SOAP notes! It's quite overwhelming, particularly for new clinicians, to consider the amount you need to document.

With practice, your note-taking skills and knowledge of what's essential will improve. But also, you'll come to realise that there are good tools to help you write comprehensive records.

Templates take away the cognitive load

The best way to make sure that you cover what you need is by creating templates. These help you to document the things you need in each section. They can also prompt you to add important details.

Templates aren't a catch-all solution though. Many clinicians create templates to cover all eventualities. Unfortunately, they then struggle to use them in real scenarios.

That means they spend a long time removing irrelevant information to make their template suit the reality of their encounter. Worse of all, they run the risk of leaving in incorrect information.

Use the right tools for your SOAP notes

Healthcare professionals are now spending more time on clinical documentation. On average this is about 13.5 hours, 25% more than in the last seven years. Of this time, around 3 hours is happening outside of working hours.

However, the accuracy of documentation has not improved. Unclear or incomplete data is the number one cause of clinicians reporting that the information they need isn’t available.

Unfortunately, time spent writing notes is time that clinicians can’t spend with patients. You have to balance the four elements of good record-keeping: clear, concise, contemporaneous and correct.

Use the right tools for your SOAP notes

That’s why Kiroku is building tools to help clinicians focus on the things that matter, whilst automating the more boring bits of work.

Our clickable note templates allow you to build custom workflows to make note-taking quick yet personalised. There's no risk of leaving in irrelevant information as your notes tailor themselves to your patient.

If you're new to practice, or want to get another perspective on note-taking, we can also help.

If you're a dental professional, you can pick from our library of stock SOAP note templates. They have been created by our clinical team for a range of appointment types. We're working to expand these out to different clinical roles too.

SOAP notes and Kiroku - all about time-saving

If you're unfamiliar with Kiroku, we're a company co-founded by a dentist and an AI engineer. Our goal is to give you the time back to focus on the things that you trained to do.

We're blending our clinical and engineering knowledge to bring you the tools that help you leave work on time, feeling fulfilled that you've spent your day providing the best care possible to your patients.

If you hate writing up notes, then Kiroku's for you. All of our templates are completely customisable. If you want to make some minor tweaks, go for it! And if you've perfected your own already, upload them into Kiroku and we'll turn them into clickable templates for you.

Find out how Kiroku is helping clinicians to reclaim their time and reduce the administrative burden. Better, more personalised notes are a breeze with Kiroku.