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.

1. 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.

1. 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.

1. 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.

1. 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.

1. 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.