Writing Better SOAP Notes in Primary Care

In primary care, a lot of time is spent on documenting patient visits, and one of the most important parts of this documentation is the SOAP note. SOAP stands for Subjective, Objective, Assessment, and Plan. It provides a format to document a patient’s condition and care plan.

For primary care physicians, knowing how to write SOAP notes is crucial for keeping accurate records, improving patient care, and communicating better with other healthcare professionals.

So, how can you write better SOAP notes? Let’s break down each section.

1. Subjective

Table of Contents

The subjective section is where you note down what the patient tells you. They could be talking about their symptoms, concerns, and health history, and you’d be basically recording their point of view.

The recording or writing part is where AI can help you be more efficient by listening to the conversation (with the patient’s consent) and transcribing the information. This information includes:

The main issue that the patient is presenting, like “I have a headache.”
Details of the patient’s current condition, like the onset, duration, and severity of the issue.
A review of other symptoms the patient is experiencing

This is where you ask questions and listen to your patient while noting everything down. For better SOAP notes for primary care physician documentation, you can:

Be specific. Avoid vague terms like “feeling sick,” and ask clarifying questions to pinpoint the issue.
Ask open-ended questions to encourage the patient to explain their symptoms in their own words.

2. Objective

The objective section, as the word suggests, is where you add in the factual findings from the physical exams or any tests performed. Here, you record measurable data, such as:

Vitals. Blood pressure, heart rate, temperature, etc.
Physical exam results and observations.
Lab and diagnostic test results. This includes any relevant lab work that helps rule out conditions.

For better objective documentation, make sure to:

Use precise terms. Don’t use subjective descriptions here.
Stay organised. List the physical exam findings systematically.
Document all relevant tests. Even if the results are normal.

3. Assessment

The assessment section outlines what you think is happening. It’s where you compare and combine the information from the subjective and objective sections to make a list of potential diagnoses.

This is basically the “thinking” part of SOAP notes, where you analyse the situation and make sense of the clinical data. For better assessment, consider:

Differential diagnosis. If you’re not completely sure about a diagnosis, list other possibilities with reasoning for why they may be less likely.
Clear and concise language. Try to be as specific as possible, and list possible diagnoses followed by evidence in the previous two sections.

4. Plan

The Plan section outlines the next step in the patient’s care, including:

Treatment plan. What medications, procedures, and/or therapies will you prescribe?
Follow-up plan. When should the patient return for the next appointment or tests?
Patient education. What should they do at home?

This section of SOAP notes should:

Be detailed. Add specifics, such as dosages, frequency, and duration, for the prescribed medications.
Include times. Clearly mention when follow-up appointments or tests should happen.
Be individualised to the patient’s needs, preferences, and understanding.