ECM 3-4 Students: Preparation

Preparation for the Session: Basics of a SOAP note

Not to be confused: Full H&P vs. a SOAP note:
Usually on the first day that a patient is admitted to your medical team or when a new patient shows up in your
outpatient clinic, a full and complete History & Physical or H&P or an admit note is written, which includes a
detailed write-up of CC, HPI, past medical history, past surgical history, family history, allergies, etc. Starting on the
second day of admission or when seeing a patient you are familiar with, a SOAP note can be written, with the goal of
documenting any NEW information and an updated assessment & plan since the last visit with the patient.
Practically speaking, this means that a SOAP note can include only the new information elicited from the patient since
the last visit. However, important information already documented in the previous notes can be repeated for
improved communication, when it is appropriate for the situation and/or depending on the personal style.

Talking about personal style

The residents and attendings youll be working with will be the best resources for feedback on your SOAP notes. Ask
them at the very beginning for their expectations on notes from medical students. Often times, for the sake of
students learning, the format can be different than what you see the residents and attendings write for themselves.
The attendings may (and often do) use your SOAP notes as part of the evaluation for your overall rotation grade. And
since each clerkship may require different SOAP note elements, it is best to ask early for guidance. Just as a
reference, several samples of SOAP notes will be provided at the completion of this session.

What is a SOAP note?

SOAP stands for Subjective, Objective, Assessment, and Plan.

Subjective: This section is for information provided to you, often verbally, by others.
This is essentially the History portion of the History & Physical, which includes pretty much everything that the
patient or the family tells you. Obtain the patients history since the last visit by asking either How were things over
night? if you saw the patient yesterday or How were things since the last visit? if you havent seen the patient in a
while.
Other pertinent things that may be included in this section include reports from the nursing staff or other new
subjective information, such as new family history information or new information obtained from hospital records.

Objective: This section is for info you can verify yourself.

This includes the vitals, fluids in/out of the body, general appearance and physical exam, labs, imaging, and
medications/procedures/surgeries that your team has performed while under your care. A mnemonic that can be
used to remember the order in which this information is commonly presented is VIP LIMPS, which stands for Vitals,
I/Os, Physical exam, Lab, Imaging, Medications, Procedures, Surgeries.
Another thing not to be confused: Medications taken at home before admission or procedures done on the patient
before being on your team would belong to the subjective aka history portion of the admit H&P or your SOAP
note.

Developed by Richard Keyme MD, Class of 2013

ECM 3-4 Students: Preparation

The medications that are provided to the patient now and the procedures that you perform yourself are objective
aka directly observed and would belong in this section.

Assessment:
Consider this portion the executive summary of the SOAP note. A lot of information has been presented so far in this
latest SOAP note, as well as in the previous SOAP notes and the admit H&P. Try to synthesize all of the information
known about the patient, including a working diagnosis and a rationale for the diagnosis.

Plan:
As a M3 medical student, you should always practice proposing a plan for your patient, but also expect that it will
often require additional input from residents and attendings. This will improve with more experience within the field,
as well as experience throughout the third year. Even though you will often have incomplete or incorrect
assessment/plan portion of the SOAP notes, its just as important to practice synthesizing it yourself. Practice will
make it almost perfect.
As a medical student, it may be more important (and expected) to include the following components:
1. Your differential diagnosis (in ranked order of likelihood) with explanation
2. The current management for the problem
3. Your proposal for the next steps in management (diagnostic, therapeutic, patient education) with
explanation
*Note: Assessment/Plan can be combined for convenience or personal preference. And just like other parts of the
SOAP note, the exact format of this section can depend on the personal style and/or the situation. Two common
approaches to A/P are system based and problem based. Whichever system you decide to use, it is important as
a medical student to provide the differential diagnosis and provide an explanation justifying the differential. Just as a
reference, in internal medicine, system based approaches are more commonly used in the ICU setting and problem
based approaches are more commonly used in the general wards. Examples are provided during the session.

And lastly, please remember to sign your note and have it reviewed by a resident or an attending:

Your full name, MS3

Additional Reference in preparation for the session:

How to write short-hand lab results:
Chem 7:

CBC:

Basic Metabolic Panel (BMP): Refers to a Chem 7 + Calcium

Developed by Richard Keyme MD, Class of 2013

ECM 3-4 Students: Preparation

Comprehensive Metabolic Panel (CMP): BMP + Albumin, Total Protein, Alkaline Phosphatase, AST, ALT, Bilirubin
Not to be confused: Do not confuse Metabolic Panel with Lipid Panel. Lipid panel is the test ordered to measure
LDL, HDL, Triglycerides, Total cholesterol, VLDL, and cholesterol:HDL ratio.
*Side note: It may take some time, but it will be useful to know the normal values for all the components above (or at
least have a general idea of when a number is grossly abnormal). Even with all the computers and electronics easily
available, it will save a significant time in the long run to have this knowledge as early as possible.

Practice Questions: Please categorize the following statements as (S) for Subjective, (O) for Objective, (A) for
Assessment, and (P) for Plan.
Eg: S Patient reports 4 out of 10 abdominal pain.
1. ___ Todays hemoglobin is 8.0
2. ___ 24 year old male with no past medical history has a 6 out of 10 non-radiating sharp forearm pain with
movement after a fall with outstretched arm, but negative for fractures or displacement on x-ray. Given
absence of swelling, full ROM on exam, and negative imaging, likely not a fracture.
3. ___ Nurse reports that the patient did not eat anything for dinner.
4. ___ On exam, patient appears to be Not in Acute Distress (NAD) and breathing comfortably.
5. ___ Dressing appears clean, dry, and intact.
6. ___ Start the patient on subcutaneous heparin for DVT prophylaxis.
7. ___ CXR taken today was normal.
8. ___ Patient reports not having any bowel movement for the third day in a row.
9. ___ Will consult interventional radiology for a possible central line placement.
10. ___ Patient was taking 1 baby aspirin and multi-vitamin (MVI) per day at home.
11. ___ 70 year old female with no complaints here for an annual follow up. Normal vitals and physical exam.
Patient up to date with immunizations, colonoscopies, DEXA scan, mammogram, and all normal previous pap
smears. No other concerns at this time.
12. ___ Discontinue antibiotics today.
13. ___ Discussed the importance of smoking cessation today.
14. ___ Patient had a shortness of breath (SOB) over night, but no complaints this morning.
15. ___ Follow up in 4 weeks.

Developed by Richard Keyme MD, Class of 2013

ECM 3-4 Students: Preparation

ANSWER KEY
1. O Todays hemoglobin is 8.0
2. A

24 year old male with no past medical history has a 6 out of 10 non-radiating sharp forearm pain with

movement after a fall with outstretched arm, but negative for fractures or displacement on x-ray. Given
absence of swelling, full ROM on exam, and negative imaging, likely not a fracture.
3. S

Nurse reports that the patient did not eat anything for dinner.

4. O On exam, patient appears to be Not in Acute Distress (NAD) and breathing comfortably.
5. O Dressing appears clean, dry, and intact.
6. P

Start the patient on subcutaneous heparin for DVT prophylaxis.

7. O CXR taken today was normal.

8. S

Patient reports not having any bowel movement for the third day in a row.

9. P

Will consult interventional radiology for a possible central line placement.

10. S

Patient was taking 1 baby aspirin and multi-vitamin (MVI) per day at home.

11. A

70 year old female with no complaints here for an annual follow up. Normal vitals and physical exam.

Patient up to date with immunizations, colonoscopies, DEXA scan, mammogram, and all normal previous pap
smears. No other concerns at this time.
12. P

Discontinue antibiotics today.

13. P

Discussed the importance of smoking cessation today.

14. S

Patient had a shortness of breath (SOB) over night, but no complaints this morning.

15. P

Follow up in 4 weeks.

Developed by Richard Keyme MD, Class of 2013