Quick answer
A SOAP note is a structured way to document a patient visit. SOAP stands for Subjective, Objective, Assessment, and Plan. Nurses, physicians, and other clinicians use it to record what the patient reports, what the clinician observes and measures, what those findings mean, and what happens next. The format keeps records clear and helps every member of the care team follow a patient’s progress over time.
What Does SOAP Stand For?
Each letter is one section of the note. Writing the sections in the same order every time makes notes faster to write and faster to read.
S: Subjective
This is what the patient says in their own words. It can include symptoms, concerns, how they have been sleeping or eating, and how they feel about their treatment. A subjective entry might read: “Client reports sleeping better this week and denies new side effects.”
O: Objective
This section holds facts the clinician can observe or measure. Examples include vital signs, weight, appearance, behavior during the visit, lab results, and which medication was given. Objective details should be specific and free of opinion.
A: Assessment
Here the clinician pulls the subjective and objective information together. The assessment explains what the findings suggest, such as whether symptoms are stable, improving, or getting worse, and whether there are any new concerns.
P: Plan
The plan lists the next steps. That might include follow-up timing, medication changes ordered by a prescriber, education given, referrals, or a note to share an update with the rest of the team.
Where Did SOAP Notes Come From?
SOAP notes grew out of the problem-oriented medical record, an approach to charting developed by physician Lawrence Weed. The idea was to organize each record around the patient’s problems so anyone reading it could follow the clinician’s reasoning. Today SOAP notes are used across medicine, nursing, mental health, and therapy, on paper and in electronic health records.
Why Do Nurses Use SOAP Notes?
- Clear communication. A nurse, a prescriber, and a case manager can all read the same note and understand what happened.
- Continuity of care. When a patient is seen by different team members, the notes show the full story.
- Tracking change. Comparing notes from visit to visit shows whether symptoms and functioning are moving in the right direction.
- An accurate record. Clinical documentation is part of the legal medical record, so it needs to be accurate and complete.
How SOAP Notes Work in Community Mental Health
In community-based psychiatric care, a nurse may see the same client many times over months. SOAP notes give each visit a consistent structure. The subjective section captures how the client describes their mood and daily life. The objective section records what the nurse observed and any medication given. The assessment notes whether symptoms look stable, and the plan sets up the next visit or a team follow-up.
What Makes a Good SOAP Note?
- It is written soon after the visit, while details are fresh.
- It keeps facts (objective) separate from interpretation (assessment).
- It uses clear language and standard abbreviations only.
- It is specific enough that another clinician could pick up care without asking questions.
- It is concise. Long notes are harder for busy teams to use.
Can Patients See Their SOAP Notes?
Under the federal HIPAA Privacy Rule, people generally have a right to access their own health records, which can include clinical notes. Ask the provider’s office or medical records department how to request them. The U.S. Department of Health and Human Services explains this right on its website, linked below.
Documentation is one part of how care teams stay coordinated. For the bigger picture, read what an interdisciplinary care team does.
Frequently Asked Questions
What are the four parts of a SOAP note?
The four parts are Subjective (what the patient reports), Objective (what is observed and measured), Assessment (what the findings mean), and Plan (the next steps).
Do nurses write SOAP notes?
Yes. Nurses in many settings, including community mental health, write SOAP notes. Physicians, therapists, and other clinicians use the format too.
What is the difference between subjective and objective in a SOAP note?
Subjective information comes from the patient, such as symptoms they describe. Objective information is what the clinician can observe or measure, such as vital signs or behavior during the visit.