Updated: October 2025
Written by: The Essayassists Team

Introduction

In nursing, psychology, and medical fields, documentation is everything. Among the most effective methods for clinical reporting is the SOAP note — a structured format that helps healthcare professionals record, analyze, and communicate patient information efficiently. Whether you’re a nursing student, a medical intern, or a psychology practitioner, learning how to write a SOAP note and develop a corresponding plan is essential. This Essayassists guide will walk you through every section with examples, tips, and a sample structure.

What is a SOAP Note?

A SOAP note is a standardized method used by healthcare professionals to document patient encounters clearly and effectively. The acronym stands for Subjective, Objective, Assessment, and Plan, each representing a vital component of clinical communication. The Subjective section records what the patient reports about their symptoms and feelings, while the Objective section lists measurable data such as vital signs, test results, and observable findings. The Assessment section involves the clinician’s professional evaluation or diagnosis based on the gathered information, and the Plan outlines the next steps for treatment, follow-up, or further testing. By following this structured approach, practitioners ensure that patient care is consistent, accurate, and well-organized, ultimately improving clinical decision-making and communication among healthcare teams.

A SOAP note is a method of documentation used to organize patient information logically. The acronym stands for:

• S – Subjective: What the patient says.
• O – Objective: What you observe or measure.
• A – Assessment: Your professional interpretation.
• P – Plan: What you’ll do next.

Each section plays a key role in understanding the patient’s current state and determining the best course of action.

Step-by-Step Guide to Formulating a SOAP Note

1.     Subjective (S)

Begin with the Subjective section, which captures the patient’s perspective in their own words. This paragraph should summarize the chief complaint (the main reason the patient sought care), the history of present illness (onset, timing, severity, modifying factors), and any relevant past medical, surgical, family, or social history that the patient volunteers. Use direct quotes for especially important statements — for example, “I’ve had stabbing pain in my chest for two hours” — to preserve accuracy, and record review-of-systems items the patient mentions that could influence diagnosis (e.g., fever, shortness of breath, recent travel). The Subjective portion is not a narrative novel: be succinct, prioritize what’s clinically relevant, and note any functional limitations the patient reports.

Example:

Patient reports feeling dizzy and nauseous for the past two days, especially after standing. States, “I feel lightheaded when I get up too fast.”

Essayassists Tip: Always use quotation marks for direct patient statements to preserve accuracy.

2.     Objective (O)

 The Objective paragraph contains what you can observe and measure: vital signs, focused physical exam findings, mental status observations, and the results of point-of-care tests or imaging available at the visit. Document specific values (e.g., BP 130/82 mmHg, HR 96 bpm) and objective signs (e.g., “left lower lung decreased breath sounds, no wheeze” or “pupil equal and reactive to light”). If you order labs or imaging that return during or immediately after the encounter, summarize the key results here. Keep objective entries factual and avoid interpretation or speculation — that belongs in the Assessment.

Here you record measurable, observable data obtained through physical exams, lab results, or diagnostic tests.

Include:

• Vital signs (temperature, pulse, blood pressure, etc.)
• Physical examination findings
• Test results or imaging
• Observations of patient behavior or appearance

Example:

BP: 110/75 mmHg, HR: 88 bpm, Temp: 36.8°C. No abnormal neurological findings. Patient appears alert but slightly pale.

Essayassists Tip: Keep it factual and concise — avoid opinions here.

3.     Assessment (A)

In the Assessment paragraph you synthesize the subjective and objective information into one or more clinical impressions or diagnostic hypotheses. Start with the most likely diagnosis, then list differential diagnoses if appropriate, and indicate how certain you are or what findings support each possibility. If this visit is part of ongoing care, note changes since the last encounter and whether the patient is improving, unchanged, or deteriorating. When relevant, include brief clinical reasoning — for instance, “assessment: community-acquired pneumonia likely based on fever, productive cough, and lobar consolidation on CXR; differential includes bronchitis.” This paragraph is where your professional judgment is recorded and justified.

This section is your professional evaluation of the patient’s condition based on the subjective and objective data.

Include:

• Possible diagnoses
• Clinical impressions
• Progress from previous visits

Example:

Assessment: Orthostatic hypotension likely due to dehydration. Differential diagnosis includes anemia or medication side effects.

Essayassists Tip: Support your assessment with logical reasoning — connect what the patient reports with what you observe.

4.     Plan (P)

The Plan paragraph translates assessment into action: specific treatments, medications (including dose and route), recommended labs or imaging, referrals, patient education, and clear instructions for follow-up. Make the plan SMART where possible — specific, measurable, achievable, relevant, and time-bound — for example, “start amoxicillin 500 mg PO TID for 7 days; follow up in 48–72 hours or sooner if fever exceeds 38.5°C or breathing worsens.” If you advise home-care measures or symptom management, state them plainly (e.g., hydration, ice, rest) and confirm the patient’s understanding when possible. Also document safety-netting instructions: exactly when the patient should seek urgent care.

The plan outlines your next steps for patient care — treatment, follow-up, or referrals.

Include:

• Medications or therapies prescribed
• Recommended lifestyle changes
• Follow-up appointments
• Patient education
• Diagnostic tests or referrals

Example:

Encourage increased fluid intake and monitor blood pressure at home. Follow-up in 3 days. If symptoms persist, schedule lab tests for anemia.

Essayassists Tip: Always make your plan actionable and time-bound.

Putting It All Together – Example SOAP Note

S: Patient reports a sore throat for four days and difficulty swallowing. Denies fever or cough.

O: Throat red with mild swelling. No exudate noted. Temp: 37.2°C, HR: 80 bpm.

A: Mild viral pharyngitis.

P: Advise warm fluids, throat lozenges, and rest. Reassess if symptoms persist beyond one week.

How to Develop an Effective Plan

Every successful healthcare interaction — whether in nursing, psychology, or medicine — ends with one crucial step: a clear, actionable plan. The Plan section of a SOAP note (Subjective, Objective, Assessment, and Plan) transforms your clinical reasoning into tangible next steps that guide treatment, promote recovery, and ensure patient safety. Developing an effective plan requires not only professional knowledge but also strong organization, communication, and critical thinking skills. In this Essayassists guide, you’ll learn exactly how to create a plan that is specific, realistic, and patient-centered.

Step 1: Review the Assessment Carefully

Before writing your plan, revisit your Assessment section. The plan should always flow logically from your clinical findings and diagnosis. Think of the assessment as the “why” and the plan as the “how.” If your assessment identifies dehydration, your plan might focus on fluid replacement and monitoring. If your assessment points to anxiety, your plan could involve counseling, relaxation techniques, or medication. A clear link between assessment and plan ensures continuity and helps other professionals easily follow your reasoning.

Step 2: Set Clear and Achievable Goals

An effective plan begins with well-defined goals. These goals should be SMART — Specific, Measurable, Achievable, Relevant, and Time-bound.
For instance, rather than writing “Patient to feel better soon,” a stronger goal is “Patient will report reduced pain level from 7/10 to 3/10 within 48 hours after initiating treatment.” Specific goals make progress measurable and motivate both the patient and healthcare provider to monitor improvement. Remember, vague goals lead to vague outcomes.

Step 3: Outline Interventions and Treatments

Once goals are established, describe the exact interventions needed to achieve them. These interventions can include:

• Medical treatments (e.g., prescribing medication, scheduling lab tests, or referring to a specialist)
• Nursing actions (e.g., wound dressing, fluid monitoring, patient education)
• Psychological interventions (e.g., cognitive-behavioral therapy, mindfulness training, or journaling exercises)

Each intervention should have a clear purpose and should address a specific aspect of the diagnosis. Always include relevant details such as dosage, frequency, duration, and method of administration when applicable.

Step 4: Provide Patient Education and Lifestyle Recommendations

Patient understanding plays a major role in successful outcomes. Include a section in your plan that explains what the patient needs to do at home, why it matters, and how to do it safely. This might include dietary changes, physical activity, medication adherence, or stress management techniques. When patients understand their care plan, they are far more likely to follow it effectively. Document exactly what education you provided and confirm the patient’s comprehension.

Step 5: Establish a Follow-Up Schedule

A good plan is never complete without a follow-up. Indicate when and how the patient should be reassessed. This could be a specific timeframe (e.g., “Follow up in 7 days for wound inspection”) or conditional (“Return sooner if swelling or pain increases”). Follow-ups allow healthcare providers to evaluate the effectiveness of interventions, modify treatment if necessary, and ensure that recovery is progressing as expected.

Essayassists Tip: A plan without follow-up instructions is incomplete — every care plan should include an evaluation timeline.

Step 6: Coordinate Care and Referrals if Needed

In many cases, a patient’s needs go beyond one provider’s scope. Include referrals to specialists, therapists, or support services as part of your plan when appropriate. For example, a diabetic patient may benefit from referrals to a nutritionist or a diabetes educator. Document all referrals clearly to maintain collaboration and prevent care gaps.

Step 7: Monitor and Document Progress

Developing an effective plan doesn’t stop once it’s written. Ongoing monitoring and documentation are vital. Record patient progress at each visit and adjust the plan as needed. Plans are dynamic — they should evolve with the patient’s condition. If an intervention isn’t working, note the changes and rationale for modifying treatment. Consistent documentation ensures accountability and provides a clear record for anyone reviewing the case.

Step 8: Communicate the Plan Clearly

A plan is only effective when everyone involved — including the patient, caregivers, and other healthcare professionals — understands it. Use clear, concise language, avoid technical jargon when explaining instructions to patients, and ensure all written documentation is legible and structured. Effective communication promotes teamwork and prevents errors, especially in multidisciplinary care settings.

Common Mistakes to Avoid When Writing a Plan

1. Vagueness: Plans like “monitor closely” or “continue current treatment” without specifics are incomplete.
2. Omitting follow-up: Always include when to reassess the patient.
3. Failing to individualize care: Copy-paste plans ignore unique patient factors.
4. Ignoring patient input: Plans work best when they align with patient goals, values, and resources.
5. Lack of documentation: If it’s not written down, it didn’t happen.

Avoiding these mistakes will make your SOAP notes professional, actionable, and credible.

Example of an Effective Plan

Assessment: Dehydration due to heat exposure.
Plan:

• Encourage oral rehydration with 2–3 liters of fluids per day.
• Administer oral rehydration salts every 8 hours for 24 hours.
• Educate patient on recognizing early signs of dehydration.
• Schedule follow-up in 2 days for reassessment of hydration status.
• Advise to avoid prolonged outdoor activity until recovery confirmed.

This example demonstrates clarity, structure, and realistic goals that can be easily followed by both the patient and the healthcare team.

Conclusion

Mastering the art of SOAP note writing is essential for effective clinical communication and patient care. By organizing information into the four key sections — Subjective, Objective, Assessment, and Plan — you create a clear, professional, and actionable record. Developing an effective plan is the final, yet most important step in any clinical documentation process. A well-written plan demonstrates professional competence, ensures continuity of care, and directly contributes to positive patient outcomes. It bridges the gap between diagnosis and action — transforming medical judgment into measurable progress.

If you find it challenging to craft detailed, accurate, and professional SOAP note plans, the experts at Essayassists.com are here to help. From customized templates to one-on-one editing support, Essayassists ensures your clinical documentation meets the highest academic and professional standards.

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FAQs on SOAP Notes

1. What does SOAP stand for in documentation?

SOAP stands for Subjective, Objective, Assessment, and Plan. These four sections form a structured method of documenting patient encounters — from what the patient reports to the clinician’s diagnosis and treatment plan.

2. Why are SOAP notes important in healthcare?

SOAP notes ensure clear communication among healthcare professionals, improve continuity of care, and provide a legal record of patient treatment. They help organize complex information logically so that every provider reviewing the chart understands the patient’s history, progress, and next steps.

3. Who uses SOAP notes?

SOAP notes are used by a wide range of professionals, including doctors, nurses, psychologists, therapists, and physical therapists. They’re common in both hospital and outpatient settings, as well as in mental health and counseling practices.

4. How often should SOAP notes be written?

SOAP notes should be written after each patient encounter or session. In ongoing therapy or treatment plans, a new SOAP note is typically added for every follow-up to track changes and progress over time.

5. How long should a SOAP note be?

A SOAP note should be concise but complete. Each section may range from a few sentences to a short paragraph, depending on the complexity of the case. Clarity and relevance are more important than length.

6. What’s the difference between Subjective and Objective data?

• Subjective data is what the patient reports — their symptoms, feelings, and experiences (e.g., “I feel dizzy”).
• Objective data includes measurable findings like vital signs, lab results, and physical observations (e.g., “BP 120/80 mmHg, Temp 37°C”).

7. Can SOAP notes be used in psychology or counseling?

Yes. In psychology, SOAP notes help therapists document client progress, record interventions, and evaluate treatment outcomes. They also support continuity of care when clients work with multiple professionals.

8. How do I make my SOAP notes more professional?

Use clear, clinical language, keep information organized under each heading, and avoid personal opinions or assumptions. Always maintain confidentiality, and focus on facts, observations, and evidence-based reasoning.

9. What are common mistakes in SOAP note writing?

Common errors include mixing subjective and objective data, omitting follow-up actions, being too vague, or failing to connect the assessment logically to the plan. Proofreading and peer feedback help eliminate these issues.

10. Can I get help writing SOAP notes for my nursing or medical coursework?

Absolutely. Essayassists.com offers professional assistance with writing, formatting, and editing SOAP notes for nursing, medical, and psychology students. The platform provides templates, expert guidance, and proofreading to help you submit accurate, polished documentation.