Skillintermediate

Patient Documentation Standards

SOAP (Subjective, Objective, Assessment, Plan) is the standard format for progress notes in clinical practice.

Claude Code Knowledge Pack7/10/2026

Overview

Patient Documentation Standards

SOAP Notes

SOAP (Subjective, Objective, Assessment, Plan) is the standard format for progress notes in clinical practice.

Purpose and Use

When to use SOAP notes:

Daily progress notes in hospital
Outpatient visit documentation
Subspecialty consultations
Follow-up visits
Documenting response to treatment

Benefits:

Standardized structure
Organized clinical reasoning
Facilitates communication
Supports billing and coding
Legal documentation

SOAP Components

S - Subjective

Definition: Information reported by the patient (symptoms, concerns, history)

Elements to include:

Chief complaint or reason for visit
History of present illness (HPI)
Review of systems (ROS) relevant to visit
Patient's description of symptoms
Response to prior treatments
Functional impact
Patient concerns or questions

HPI Elements (use OPQRST for pain/symptoms):

Onset: When did it start? Sudden or gradual?
Provocation/Palliation: What makes it better or worse?
Quality: What does it feel like? (sharp, dull, burning, etc.)
Region/Radiation: Where is it? Does it spread?
Severity: How bad is it? (0-10 scale)
Timing: Constant or intermittent? Duration? Frequency?

Associated symptoms:

Other symptoms occurring with primary complaint
Pertinent negatives (absence of expected symptoms)

Response to treatment:

Medications taken and effect
Prior interventions and outcomes
Compliance with treatment plan

Example Subjective section:

S: Patient reports persistent cough for 5 days, productive of yellow sputum. Associated
with fever to 101.5°F, measured at home yesterday. Denies shortness of breath, chest
pain, or hemoptysis. Started on azithromycin 2 days ago by urgent care, with minimal
improvement. Reports decreased appetite but able to maintain hydration. Denies recent
travel or sick contacts.

O - Objective

Definition: Measurable, observable clinical data

Elements to include:

Vital Signs:

Temperature (°F or °C)
Blood pressure (mmHg)
Heart rate (bpm)
Respiratory rate (breaths/min)
Oxygen saturation (%)
Height and weight (calculate BMI)
Pain score if applicable

General Appearance:

Overall appearance (well, ill, distressed)
Age appropriateness
Nutritional status
Hygiene
Affect and behavior

Physical Examination by System:

Organized head-to-toe or by systems
Relevant findings for presenting complaint
Include pertinent positives and negatives

Standard examination systems:

HEENT (Head, Eyes, Ears, Nose, Throat)
Neck (thyroid, lymph nodes, JVD, carotids)
Cardiovascular (heart sounds, murmurs, peripheral pulses, edema)
Pulmonary/Respiratory (breath sounds, work of breathing)
Abdomen (bowel sounds, tenderness, organomegaly, masses)
Extremities (edema, pulses, ROM, deformities)
Neurological (mental status, cranial nerves, motor, sensory, reflexes, gait)
Skin (rashes, lesions, wounds)
Psychiatric (mood, affect, thought process/content)

Laboratory and Imaging Results:

Relevant test results
Include reference ranges for abnormal values
Note timing of tests relative to visit

Example Objective section:

O: Vitals: T 100.8°F, BP 128/82, HR 92, RR 18, SpO2 96% on room air
General: Alert, mild respiratory distress, appears mildly ill
HEENT: Oropharynx without erythema or exudates, TMs clear bilaterally
Neck: No lymphadenopathy, no JVD
Cardiovascular: Regular rate and rhythm, no murmurs
Pulmonary: Decreased breath sounds right lower lobe, dullness to percussion, egophony
present. No wheezes.
Abdomen: Soft, non-tender, no organomegaly
Extremities: No edema, pulses 2+ bilaterally
Neurological: Alert and oriented x3, no focal deficits

Labs (drawn today):
WBC 14.2 x10³/μL (H) [ref 4.5-11.0]
Hemoglobin 13.5 g/dL
Platelets 245 x10³/μL
CRP 8.5 mg/dL (H) [ref <0.5]

Chest X-ray: Right lower lobe consolidation consistent with pneumonia

A - Assessment

Definition: Clinical impression, diagnosis, and evaluation of patient status

Elements to include:

Primary diagnosis or problem
Secondary diagnoses or problems
Differential diagnosis if uncertain
Severity assessment
Progress toward treatment goals
Complications or new problems

Format:

Problem list (numbered)
Each problem with brief assessment
Include ICD-10 codes when appropriate for billing

Example Assessment section:

A: 
1. Community-acquired pneumonia (CAP), right lower lobe (J18.1)
   - Moderate severity (CURB-65 score 1)
   - Appropriate for outpatient management
   - Minimal improvement on azithromycin, likely bacterial etiology
   
2. Dehydration, mild (E86.0)
   - Secondary to decreased PO intake
   
3. Type 2 diabetes mellitus (E11.9)
   - Well-controlled, continue home medications

P - Plan

Definition: Diagnostic and therapeutic interventions

Elements to include:

Diagnostic plan (further testing, imaging, referrals)
Therapeutic plan (medications, procedures, therapies)
Patient education and counseling
Follow-up arrangements
Specific instructions for patient
Return precautions (when to seek urgent care)

Medication documentation:

Drug name (generic preferred)
Dose and route
Frequency
Duration
Indication

Plan organization:

By problem (matches assessment)
By intervention type (diagnostics, therapeutics, education)

Example Plan section:

P:
1. Community-acquired pneumonia:
   Diagnostics: None additional at this time
   Therapeutics:
   - Discontinue azithromycin
   - Start amoxicillin-clavulanate 875/125 mg PO BID x 7 days
   - Supportive care: adequate hydration, rest, acetaminophen for fever
   Education: 
   - Explained bacterial pneumonia diagnosis and antibiotic change
   - Discussed expected improvement within 48-72 hours
   - Return precautions: worsening dyspnea, high fever >103°F, confusion
   Follow-up: Phone call in 48 hours to assess response, clinic visit in 1 week
   
2. Dehydration:
   - Encourage PO fluids, goal 2 liters/day
   - Sports drinks or electrolyte solutions acceptable
   
3. Type 2 diabetes:
   - Continue metformin 1000 mg PO BID
   - Home glucose monitoring
   - Follow-up with endocrinology as scheduled

Patient verbalized understanding and agreement with plan.

SOAP Note Best Practices

Documentation standards:

Write legibly if handwritten
Use standard abbreviations only
Date and time each entry
Sign and credential all entries
Document in real-time or as soon as possible
Avoid copy-forward errors
Review and update problem list

Billing considerations:

Document medical necessity
Match documentation to billing level
Include required elements for E/M coding
Document time for time-based billing

Legal considerations:

Document facts, not opinions or judgment
Quote patient when relevant
Document non-compliance objectively
Never alter records
Use addendums for corrections

History and Physical (H&P)

Purpose

Comprehensive baseline assessment
Document patient status at admission or initial encounter
Guide diagnosis and treatment planning
Required within 24 hours of admission (TJC requirement)

H&P Components

Header Information

Patient name, DOB, MRN
Date and time of examination
Admitting diagnosis
Attending physician
Service
Location (ED, floor, ICU)

Chief Complaint (CC)

Definition: Brief statement of why patient is seeking care

Format:

One sentence
Use patient's own words (in quotes)
Example: CC: "I can't catch my breath"

History of Present Illness (HPI)

Purpose: Detailed chronological narrative of current problem

Required elements (for billing):

Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs/symptoms

Structure:

Opening statement (demographics, presenting problem)
Chronological description
Symptom characterization
Prior workup or treatment
What prompted presentation now

Example:

HPI: Mr. Smith is a 65-year-old man with history of CHF (EF 35%) who presents with
3 days of progressive dyspnea on exertion. Patient reports dyspnea now occurs with
walking 10 feet (baseline 1-2 blocks). Associated with orthopnea (now requiring
3 pillows, baseline 1) and lower extremity swelling. Denies chest pain, palpitations,
or syncope. Reports medication compliance but notes running out of furosemide 2 days
ago. Weight increased 8 lbs over past week. Has not been monitoring daily weights
at home. Presented to ED today when dyspnea worsened and developed while at rest.

Past Medical History (PMH)

Include:

Chronic medical conditions
Previous hospitalizations
Major illnesses
Injuries
Childhood illnesses (if relevant)

Format:

PMH:
1. Heart failure with reduced ejection fraction (2018), EF 35% on echo 6 months ago
2. Coronary artery disease, s/p CABG (2019)
3. Type 2 diabetes mellitus (2010)
4. Hypertension (2005)
5. Chronic kidney disease stage 3 (baseline Cr 1.8 mg/dL)
6. Hyperlipidemia

Past Surgical History (PSH)

Include:

All surgeries and procedures
Dates (year acceptable if exact date unknown)
Complications if any

Format:

PSH:
1. CABG x4 (2019), complicated by post-op atrial fibrillation
2. Cholecystectomy (2015)
3. Appendectomy (childhood)

Medications

Documentation:

Generic name preferred
Dose, route, frequency
Indication if not obvious
Include over-the-counter medications
Herbal supplements
Note if patient unable to provide list

Format:

Medications:
1. Furosemide 40 mg PO daily (ran out 2 days ago)
2. Carvedilol 12.5 mg PO BID
3. Lisinopril 20 mg PO daily
4. Spironolactone 25 mg PO daily
5. Metformin 1000 mg PO BID
6. Atorvastatin 40 mg PO daily
7. Aspirin 81 mg PO daily
8. Multivitamin daily

Allergies

Document:

Drug allergies with reaction
Food allergies
Environmental allergies
NKDA if no known allergies

Format:

Allergies:
1. Penicillin → anaphylaxis (childhood)
2. Shellfish → hives
3. ACE inhibitors → angioedema

Family History (FH)

Include:

First-degree relatives (parents, siblings, children)
Age and health status or age at death and cause
Relevant hereditary conditions
Family history of presenting condition if relevant

Format:

Family History:
Father: CAD, MI age 58, alive age 85
Mother: Breast cancer, deceased age 72
Brother: Type 2 diabetes
Sister: Healthy
Children: 2 sons, both healthy

Social History (SH)

Include:

Tobacco use (current, former, never; pack-years if applicable)
Alcohol use (drinks per week, CAGE questions if indicated)
Illicit drug use (current, former, never; type and route)
Occupation
Living situation (alone, with family, assisted living, etc.)
Marital status
Sexual history (if relevant)
Exercise habits
Diet
Functional status

Format:

Social History:
Tobacco: Former smoker, quit 10 years ago (30 pack-year history)
Alcohol: 2-3 beers per week, denies binge drinking
Illicit drugs: Denies
Occupation: Retired electrician
Living situation: Lives at home with wife, 2-story house, bedroom upstairs
Marital status: Married
Exercise: Unable to exercise due to dyspnea
Diet: Low sodium diet (usually adherent)
Functional status: Independent in ADLs at baseline

Review of Systems (ROS)

Purpose: Systematic screening for symptoms by body system

Requirements:

Minimum 10 systems for comprehensive exam
Pertinent positives and negatives
"All other systems reviewed and negative" acceptable if documented

Systems:

Constitutional: Fever, chills, night sweats, weight change, fatigue
Eyes: Vision changes, pain, discharge
ENT: Hearing loss, tinnitus, sinus problems, sore throat
Cardiovascular: Chest pain, palpitations, edema, claudication
Respiratory: Cough, dyspnea, wheezing, hemoptysis
Gastrointestinal: Nausea, vomiting, diarrhea, constipation, abdominal pain
Genitourinary: Dysuria, frequency, hematuria, incontinence
Musculoskeletal: Joint pain, swelling, stiffness, weakness
Skin: Rashes, lesions, itching, changes in moles
Neurological: Headache, dizziness, syncope, seizures, weakness, numbness
Psychiatric: Mood changes, depression, anxiety, sleep disturbance
Endocrine: Heat/cold intolerance, polyuria, polydipsia
Hematologic/Lymphatic: Easy bruising, bleeding, lymph node swelling
Allergic/Immunologic: Seasonal allergies, frequent infections

Format:

ROS:
Constitutional: Denies fever, chills. Reports fatigue and weight gain (8 lbs).
Cardiovascular: Reports dyspnea, orthopnea, lower extremity edema. Denies chest pain,
palpitations, syncope.
Respiratory: Denies cough, wheezing, hemoptysis.
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
All other systems reviewed and negative.

Physical Examination

General organization:

Vital signs first
General appearance
Systematic examination head-to-toe

Vital signs:

Vitals: T 98.2°F, BP 142/88, HR 105, RR 24, SpO2 88% on room air → 95% on 2L NC
Height: 5'10", Weight: 195 lbs (baseline 187 lbs), BMI 28

System examinations:

General: Well-developed, obese man in moderate respiratory distress, sitting upright in bed

HEENT:

Head: Normocephalic, atraumatic
Eyes: PERRLA, EOMI, no scleral icterus
Ears: TMs clear bilaterally
Nose: Nares patent, no discharge
Throat: Oropharynx without erythema or exudates

Neck: Supple, no lymphadenopathy, JVP elevated to 12 cm, no thyromegaly

Cardiovascular:

Inspection: No visible PMI
Palpation: PMI laterally displaced
Auscultation: Tachycardic regular rhythm, S3 gallop present, 2/6 holosystolic murmur at apex radiating to axilla
Peripheral pulses: 2+ radial, 1+ dorsalis pedis bilaterally

Pulmonary:

Inspection: Increased work of breathing, using accessory muscles
Palpation: Tactile fremitus symmetric
Percussion: Dullness to percussion at bilateral bases
Auscultation: Bilateral crackles halfway up lung fields, no wheezes

Abdomen:

Inspection: Obese, no distention
Auscultation: Normoactive bowel sounds
Percussion: Tympanic
Palpation: Soft, non-tender, no masses, no hepatosplenomegaly

Extremities: 3+ pitting edema to mid-calf bilaterally, no cyanosis or clubbing

Skin: Warm and dry, no rashes

Neurological:

Mental status: Alert and oriented to person, place, time
Cranial nerves: II-XII intact
Motor: 5/5 strength all extremities
Sensory: Intact to light touch
Reflexes: 2+ symmetric
Gait: Deferred due to respiratory distress
Cerebellar: Finger-to-nose intact

Psychiatric: Anxious affect appropriate to illness, normal thought process