How to Write Effective Soap Notes

Subjective

1). Initiate an interview with the patient.
2). Ask how old issues are coming along and whether there are any new complaints.
3). Seek details. Ask questions such as: When does it happen? How does it feel? What did you do? How many times? Where does it hurt?
4). Ask what other medical practitioners the patient has seen. Ask what the other doctors or nurses have told him.
5). Find out what is new or has changed in the patient's life. Ask how it is affecting her health and state of mind.

1). Obtain objective information by observation and testing. The data will be a record of what you observe and what the tests show.
2). Begin with the patient's vital signs: height, weight, blood pressure, pulse, temperature.
3). Conduct a basic physical exam, from general appearance to reflexes, and note anything that has changed from the previous visit.
4). Add any new hard data, such as laboratory results, to the patient's record.

1). Evaluate the information you have obtained.
2). Make a diagnosis, or record what you suspect.
3). Summarize or even list ongoing problems with the patient's current status -- stable, progressing, improved, resolved and so on -- and any new complaints.

1). Record what you intend to do with the information you have obtained.
2). Include medication changes -- started, discontinued, increased, decreased -- and referrals to specialists, tests ordered, recommendations and instructions to the patient.
3). State when or if the patient should return for follow-up