SOAP note template

Focus on measurable, observable data in the objective section. Document vital signs, physical examination findings, test results, and your direct observations of the patient. Avoid interpretations or judgments here—save those for the assessment section. Be specific with measurements and use standard medical terminology for consistency across provider documentation.

A strong assessment section synthesizes the subjective and objective information into a clinical judgment. Clearly state your primary diagnosis or impression, include differential diagnoses when appropriate, and briefly explain your clinical reasoning. This section demonstrates your diagnostic thought process and justifies your treatment decisions based on the collected data.

Focus on accuracy, completeness, timeliness, and legibility (if handwritten). Include dates and times, identify yourself clearly, document all clinical decisions and their rationales, note patient consent discussions, and avoid subjective judgments about patients. Regular audits of your documentation can help identify areas for improvement.

Avoid vague language, undated entries, inappropriate abbreviations, copying previous notes without updates, and documenting subjective interpretations as facts. Don’t omit pertinent negative findings, leave blank spaces, or include personally biased comments. Always verify that your documentation accurately reflects the actual encounter.