Medical SOAP note template

The assessment section contains your clinical analysis and diagnosis based on subjective and objective information gathered. It’s where you interpret findings and identify problems. The plan section outlines specific actions to address those problems—including treatments, medications, referrals, patient education, and follow-up instructions. Think “what’s happening” versus “what we’ll do about it.”

Start by using consistent terminology and abbreviations approved by your facility. Focus on relevant information rather than documenting everything. Consider using templates with pre-populated sections for common conditions. Document concurrently during or immediately after patient encounters when details are fresh. Digital tools with voice-to-text capabilities can also significantly reduce documentation time.

Avoid vague subjective statements without context, missing objective data relevant to the complaint, assessment sections without clear reasoning, and plans lacking specific instructions or timelines. Don’t use unapproved abbreviations, include judgmental language, or document irrelevant information. Also avoid copying previous notes without updating information or documenting late without indicating when the actual encounter occurred.

Document sensitive information factually and professionally, using medical terminology rather than colloquial language. Include only information relevant to care. For mental health or abuse concerns, quote the patient directly when appropriate and document your objective observations separately. Follow your organization’s protocols for flagging sensitive information and ensure proper access controls are in place.