---
name: soap-progress-note-format
source: https://app.decimal.ai/s/soap-progress-note-format@1/SKILL.md
source_sha256: 1889c371f6f8
---

# SOAP progress-note format

## Contract

Enforce the SOAP progress-note format for any clinical progress/follow-up note: the note MUST be
divided into exactly four labeled sections in the fixed order **Subjective, Objective, Assessment,
Plan**, and each piece of information MUST land in its correct section. Apply whenever asked to write,
document, or write up an encounter, visit, or progress note for the chart / medical record.

## Rules

1. **Four sections, fixed order, fixed labels.** Emit exactly `Subjective`, `Objective`, `Assessment`,
   `Plan` (in that order). The single-letter abbreviations `S:` `O:` `A:` `P:` are acceptable as
   headers. Never write the note as one continuous narrative paragraph, and never substitute a different
   header scheme such as *History / Exam / Diagnosis / Treatment / Recommendations*.

2. **Subjective = what the patient reports.** Only patient- (or caregiver-) reported information belongs
   here: chief complaint, history of present illness, symptom descriptions in the patient's terms,
   pertinent review of systems, relevant history, and adherence. Nothing you measured or observed.

3. **Objective = what you measured or observed.** Vital signs, physical-examination findings, and the
   numeric results of labs / imaging / tests go here — and ONLY here. Report the raw values; do not state
   the diagnosis in this section.

4. **Assessment = your synthesis.** The named diagnosis / clinical impression, the problem list, the
   differential, and the clinical reasoning (severity, stability, progress) go here. Not raw data, and
   not the treatment orders.

5. **Plan = the forward actions.** Tests to order, treatments and medications (with dose / route /
   frequency where given), referrals, patient education, disposition, and follow-up timing go here — not
   the diagnosis itself.

6. **Allocation is the point.** The arbitrary specifics the note must respect:
   - Vital signs and exam findings → **Objective** (never Subjective).
   - The patient's stated symptoms → **Subjective** (never relabeled as Objective findings).
   - Lab / imaging numeric results → **Objective**; their interpretation / diagnosis → **Assessment**.
   - The named diagnosis → **Assessment** (never Objective, never Plan).
   - Medications, ordered tests, follow-up → **Plan** (never Assessment).

## Worked examples

**Base default (narrative — wrong) → SOAP (right):**

> BEFORE: "Mr. C returns for his COPD. He says he is coughing more and gets winded walking to the
> mailbox. His oxygen saturation is 92% and he has scattered wheezes. This looks like a COPD flare, so
> I'll start prednisone and an antibiotic and see him back in two weeks."

> AFTER:
> `Subjective:` Increased cough; dyspnea on minimal exertion (winded walking to the mailbox).
> `Objective:` SpO2 92% on room air; scattered expiratory wheezes bilaterally.
> `Assessment:` Acute COPD exacerbation.
> `Plan:` Start oral prednisone taper and azithromycin; return in 2 weeks; return sooner if worsening.

**Misallocation (wrong) → corrected:** placing measured data in the wrong section.

> BEFORE (wrong): `Subjective:` "Blood pressure 150/94, knee swollen and tender on exam."
> AFTER (right): those are measured/observed, so they belong in `Objective:` "BP 150/94; right knee with
> effusion and joint-line tenderness." The Subjective section instead carries what the patient said
> ("aching right knee, worse with stairs").

## Edge cases & exceptions

- **Multiple problems.** List each problem in `Assessment`; the `Plan` may be one combined block or a
  per-problem plan — but keep the single four-section shell.
- **Patient-reported measurements.** A value the patient *reports* (e.g., "my home readings were around
  150/95") stays in `Subjective` because it is reported; a value *you* record in clinic goes in
  `Objective`.
- **Telehealth / no exam performed.** `Objective` may hold only what you could verify, or note "exam
  deferred"; do not migrate reported symptoms into `Objective` to fill the section.
- **Normal / unremarkable exam.** Still goes in `Objective` (e.g., "Exam unremarkable"), not omitted and
  not merged into another section.

## Do / Don't

- **Do** label all four sections explicitly. **Don't** merge the note into a single prose paragraph.
- **Do** put vital signs and exam findings under `Objective`. **Don't** put them under `Subjective`.
- **Do** state the diagnosis under `Assessment`. **Don't** bury it in `Objective`.
- **Do** place ordered tests, medications, and follow-up under `Plan`. **Don't** list them in
  `Assessment`.
- **Do** keep the patient's reported symptoms in `Subjective`. **Don't** recast them as Objective
  findings.

## Common mistakes

- Writing a single narrative paragraph with no section headers at all.
- Using an alternate header scheme (History / Exam / Impression / Recommendations) instead of S/O/A/P.
- Vital signs or exam findings placed in `Subjective`.
- The diagnosis stated inside the `Objective` section.
- Orders, medications, or follow-up folded into `Assessment` instead of `Plan`.

## Quick checklist

- [ ] Four sections present, in order: Subjective → Objective → Assessment → Plan.
- [ ] Patient-reported symptoms only in Subjective.
- [ ] Vitals, exam, and lab/imaging values only in Objective.
- [ ] Named diagnosis / impression in Assessment.
- [ ] Tests, medications, and follow-up in Plan.