How do you write a good SOAP note?

The SOAPIER acronym offers a structured approach to organizing patient information for effective documentation while also streamlining the patient care workflow:

Subjective: Note the patient’s symptoms and experiences, recording any discernible patterns or contributing factors.

Objective: Record the measurable facts—vital signs, lab and imaging results, and physical exam findings.

Assessment: Interpret the subjective and objective data to formulate diagnoses, clinical impressions, and prognoses.

Plan: Outline the steps to address the patient’s needs – additional diagnostics, treatments, and referrals.

Interventions: Use this section to record the treatments(s) provided at this clinical encounter. For example, at an initial evaluation, record the patient education given.

Evaluation: Assess the immediate effectiveness or response to any intervention(s) provided to the patient. Additionally, use this section to assess patient response over time.

Revision: Update or change the plan based on new information or changes in the patient’s condition to optimize patient outcomes.

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