What is a SOAP note?A Subjective, Objective, Assessment, and Plan (SOAP) note is used to document a patient interaction. SOAP notes can vary greatly between different fields, but all SOAP notes include Subjective, Objective, Assessment, and Plan sections (the plan is inclusive of the procedures delivered). A SOAP note should include information pertaining to the patient’s treatment history and care provided during the dated treatment interaction/episode. It should also contain foundational information from the patient interaction that allows for thorough collaboration with other healthcare practitioners, allowing for the integration of various modalities of care.
A SOAP note can lead to improved patient care by helping healthcare professionals better document and apply details about a specific patient, and related collaborative and integrative care approaches. Since SOAP notes are typically read by other healthcare providers and/or those associated with insurance companies and litigation, it is essential that they are thorough and a snapshot of each completed treatment episode.
Please visit the Purdue Online Writing Lab and the National Institutes of Health, National Library of Medicine to learn more about SOAP notes.
How to write SOAP notes for the insurance billing process?
SOAP notes are used (along with other relevant healthcare documentation) as the backbone of the insurance billing process to justify/substantiate the care delivered and the medical codes associated with that delivery. These are the main components of an insurance claim for payment. Therefore, for insurance billing purposes, SOAP notes should reflect the medical necessity of the services provided.
Writing Tips:
- Be concise but thorough.
- Use accurate and specific language, but avoid medical jargon/abbreviations that may not be understood by insurance reviewers.
- Focus on using the information and data in the Subjective (patient’s report) and Objective (practitioner’s observations) sections to make an unbiased, data-driven evaluation, assessment and plan.
- Support any patient reported details, or practitioner observations in your SOAP notes with data-driven facts. The assessment and plan is best driven by research informed care.
- Be familiar with specific documentation requirements or guidelines from various insurance carriers.
Formatting Tips:
Subjective: This section can be seen as the “history” section (i.e., History of Present Illness [HPI]). You can include symptom dimensions, a chronological narrative of the patient’s complaints, information obtained from other sources (always identify the source if it is not the patient), pertinent past medical history, a pertinent review of systems (e.g., “Patient has not had any stiffness or loss of motion of other joints”), and current medications (list with daily dosages).
Objective: This section is the physical exam and laboratory data section. This section focuses on the physical exam and all pertinent labs, X-rays, etc. completed at the visit. This section includes facts that can be verified, such as vital signs, labs, swelling, discoloration, etc. This section can also include outside notes information.
Assessment/Problem List: This section is your assessment of the patient’s problems. For example:
- Assessment: A one sentence description of the patient and major problem.
- Problem list: A numerical list of problems identified.
All listed problems need to be supported by findings in the subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can. For example, “low back sprain caused by radiculitis involving the left 5th LS nerve root.” Provide at least 2 differential diagnoses (East Asian diagnosis/Western diagnosis) for the major new problem identified in your note.
Plan: This section is your plan for the patient based on the problems you’ve identified. Develop a diagnostic and treatment plan for each differential diagnosis. Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc. Your treatment plan should include patient education, pharmacotherapy (if any), and other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.). Also see the Bates’ Guide to Physical Examination and History Taking for excellent examples of complete History and Physical Exam (H&P) and SOAP note formats.
Sample Language:
- Acupuncture with points used for treatment listed; Ashi points with or without e-stim.
- Accessory techniques performed/location of techniques used: tuina, cupping, guasha, if oils or liniments were used, etc.
- Number of treatments planned before reevaluation.
- Education information: qi gong, diet, meditation, sleep suggestions, herbals or supplementation.
Please visit Purdue Online Writing Lab for more information on SOAP Note section.
