University of Vermont Graduate Writing Center
SOAP Notes: A Writer’s Guide
What is a SOAP Note?
A SOAP note is a written document that a healthcare professional creates to describe a session with a
patient/client. The information included is: Subjective, Objective, Assessment, Plan (SOAP).
Many fields rely on SOAP notes to transfer information between professionals. The usefulness of SOAP notes is
evident based on the following example:
A speech-language pathologist (SLP) named Maura receives an order to check on the swallowing
function of a hospitalized patient who has been recovering from a stroke for the past week. Though
Maura has never seen the patient before, the patient has been seen by other SLPs during her stay.
Before the SLP goes to see the patient, she will look at the hospital’s electronic documentation system
to read the patient’s chart. While doing so, she reads the SOAP note that another SLP wrote about this
patient when they treated her 2 days before. It contains important information regarding the
treatment approaches that were taken and recommendations for future treatment. Now Maura is
prepared to see this patient, knowing where she stands in the course of her treatment.
This is just one example of the usefulness of SOAP notes. They may also help a professional track the progress
of a patient and understand the other types of treatment and therapy the patient is receiving.
When Writing a SOAP Note:
Do
Be concise
Be specific
Write in the past tense
Don’t
Make general statements
Use words like “seem” and “appear”
You’ll find an example of a complete SOAP Note at the end of this handout.
The Parts of a SOAP Note (in order!):
Subjective
This is typically the shortest section (only 2-3 sentences, usually) and it describes the patient’s affect, as the
professional sees it. This information is all subjective (it isn’t measureable).
Include information that may have affected the patient’s performance, such as if they were sick, tired,
attentive, distractible, etc.
Was the patient on time or did they come late?
May include a quote of something the patient said, or how they reported feeling
