How to Document a Patient Assessment (SOAP)

Documenting a patient assessment in the notes is something all medical students need to practice. This guide discusses the SOAP framework (Subjective, Objective, Assessment, Plan), which should help you structure your documentation in a clear and consistent manner. You might also find our other documentation guides helpful.

Subjective

The subjective section of your documentation should include how the patient is currently feeling and how they’ve been since the last review in their own words.

As part of your assessment, you may ask:

• “How are you today?”
• “How have you been since the last time I reviewed you?”
• “Have you currently got any troublesome symptoms?”
• “How is your nausea?”

If the patient mentions multiple symptoms you should explore each of them, having the patient describe them in their own words.

You should document the patient’s responses accurately and use quotation marks if you are directly quoting something the patient has said.

Objective

The objective section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.

Objective observations

Appearance

Document the patient’s appearance (e.g. “The patient appeared to be very pale and in significant discomfort.”).

Vital signs

Document the patient’s vital signs:

• Blood pressure
• Pulse rate
• Respiratory rate
• SpO₂ (also document supplemental oxygen if relevant)
• Temperature (including any recent fevers)

Fluid balance

An assessment of the patient’s fluid intake and output including:

• Oral fluids
• Nasogastric fluids/feed
• Intravenous fluids
• Urine output
• Vomiting
• Drain output/stoma output

Clinical examination findings

Some examples of clinical examination findings may include:

• “Widespread expiratory wheeze on auscultation of the chest.”
• “The abdomen was soft and non-tender.”
• “The pulse was irregular.”
• “There were no cranial nerve deficits noted.”

Investigation results

Some examples of investigation results include:

• Recent lab results (e.g. blood tests/microbiology)
• Imaging results (e.g. chest X-ray/CT abdomen)

Assessment

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.

Summarise the salient points:

• “Productive cough (green sputum)”
• “Increasing shortness of breath”
• “Tachypnea (respiratory rate 22) and hypoxia (SpO₂ 87% on air)”
• “Right basal crackles on auscultation”
• “Raised white cell count (15) and CRP (80)”
• “Chest X-ray revealed increased opacity in the right lower zone, consistent with consolidation”

Document your impression of the diagnosis (or differential diagnosis):

• “Impression: community-acquired pneumonia”

If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:

• “On day 3 of treatment for community-acquired pneumonia”
• “Reduced shortness of breath and improved cough”
• “Oxygen saturations 98% on air, respiratory rate 15”
• “CRP decreasing (20), white cell count decreasing (11)”
• “Impression: resolving community-acquired pneumonia”

Plan

The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review.

Items you to include in your plan may include:

• Further investigations (e.g. laboratory tests, imaging)
• Treatments (e.g. medications, intravenous fluids, oxygen, nutrition)
• Referrals to specific specialties
• Review date/time (e.g. “I will review at 4 pm this afternoon.”)
• Frequency of observations and monitoring of fluid balance
• Planned discharge date (if relevant)