SOAP NOTE

S – Subjective: What the patient says about their symptoms, concerns, and history.

Include:

• Chief complaint (CC) in the patient’s own words.

• History of present illness (HPI).

• Relevant past medical, surgical, family, and social history.

• Review of systems (ROS) related to the complaint.

Example: “Patient reports a dull headache for the past 3 days, worse in the mornings, relieved slightly by rest.”

O – Objective: What you observe or measure during the exam.

Include:

• Vital signs (BP, HR, Temp, RR, SpO₂).

• Physical exam findings.

• Lab results, imaging, or other diagnostic data.

Example: BP 138/86 mmHg, Temp 37.2°C, mild tenderness over frontal sinuses, no neurological deficits.

A – Assessment: Your clinical impression based on subjective and objective data.

Include:

• Primary diagnosis (or working diagnosis).

• Differential diagnoses if not certain.

Example: Likely tension-type headache; differential includes sinusitis and migraine.

P – Plan: What you will do next for the patient?

Include:

• Diagnostic tests to order.

• Medications prescribed.

• Lifestyle or home care advice.
  

• Follow-up instructions.

Example: Recommend increased hydration, OTC analgesics as needed, sinus rinse, follow-up in 5 days or sooner if symptoms worsen.