To write a SOAP note, describe a patient's current condition in narrative form, and add objective details and traceable facts about the patient's health. Examine these facts, and write a diagnosis as well as a treatment plan based on the patient's current condition and symptoms.
- Write a subjective description of the patient's health
Describe the patient's pain in narrative form, including severity and quality. Include a narrative of the onset of pain, including chronology, treatment, modifying factors, such as at-home remedies or activities that lessen or increase pain, and additional symptoms.
- Write an objective description of the patient's health
Describe the patient's physical status. The facts included should be repeatable and traceable. Include information such as vital signs, results of physical examinations, lab results and intake measurements such as the patient's height and weight.
- Write an assessment
Describe the possible diagnosis or diagnoses based on the subjective and objective observations detailed in the prior sections. This could include a differential diagnosis based on the presenting symptoms. This section should also discuss the cause of the patient's symptoms and the relevant risk factors.
- Write a plan for treatment
Describe the treatment plan for the patient, including referrals, lab orders, medications and potential procedures.