Summarize the following:
At the top of your note, write down the patient’s age and sex. Along with age and sex, write the patient’s concern or why they came in for treatment. This can help other medical professionals get an idea of diagnoses or treatments at a glance. For example, you may write, “45-year-old female presenting with abdominal pain,” as the first step in your SOAP note. Write down all of the information that you took while working with the patient. Be sure to keep the information in order of Subjective-Objective-Assessment-Plan so other medical professionals looking through the SOAP note don’t get lost. You can choose to either use bullet points or write full sentences for notes as long as they are clear and concise. 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. Many systems in clinics have secure forms you can fill out on your computer so the information can be passed around quickly. However, your workplace may require you to take SOAP notes by hand. Make sure you follow the format your workplace uses closely so it stays organized.
Include the patient’s age, sex, and concern at the top of the note. Organize the parts of your note in order. Write or type the SOAP note depending on what your workplace prefers.