SOAP Note: Clinical Structure, Template, Worked Example, and LOINC/FHIR Mapping

A SOAP note is a standardized clinical documentation format that organizes a patient encounter into four sequential sections: Subjective, Objective, Assessment, and Plan. Introduced in 1968 by Lawrence L. Weed, MD, as the core progress-note structure of the Problem-Oriented Medical Record (POMR), the SOAP note links patient-reported symptoms and measurable physical or diagnostic findings directly to clinical reasoning, LOINC-coded EHR sections, and auditable source records in clinical care and research.

What Is a SOAP Note and What Does SOAP Stand For?

Before Lawrence Weed introduced the Problem-Oriented Medical Record in the New England Journal of Medicine (1968), hospital and outpatient medical charts typically consisted of unstructured chronological narratives where symptoms, physical findings, and treatment changes were interleaved without a consistent index. The SOAP note solved this by enforcing a four-part cognitive and documentary sequence for every numbered clinical problem:

• S — Subjective: The patient’s own narrative of their symptoms, chief complaint (CC), history of present illness (HPI), past medical/surgical/family/social history, current medications, allergies, and review of systems (ROS).
• O — Objective: Quantifiable, reproducible observations gathered by the clinician, including vital signs, targeted physical examination findings, point-of-care test results, laboratory panels, and diagnostic imaging reports.
• A — Assessment: The clinician’s synthesis of the Subjective and Objective evidence, stating the primary working diagnosis (or problem status for established conditions), clinical severity or trajectory, and reasoned differential diagnoses.
• P — Plan: The actionable management steps organized by problem, covering further diagnostic testing, medication or procedural orders, non-pharmacological interventions, patient education, referrals, and follow-up timing.

In formal academic and clinical manuscripts citing medical documentation standards, this guide follows the current style editions: APA 7th edition (2020), MLA 9th edition (2021), and Chicago Manual of Style 18th edition (2024), alongside the NCBI StatPearls clinical reference standard (Podder et al., SOAP Notes).

SOAP Note Structure and HL7 / LOINC Informatics Mapping

In modern certified Electronic Health Records (EHRs), clinical quality reporting (hospital and ambulatory eCQMs), and clinical data abstraction for research registries, a SOAP note is not merely free text. When exported via HL7 Consolidated Clinical Document Architecture (C-CDA) Progress Note templates or HL7 FHIR Composition and DocumentReference resources, each SOAP component maps to standard Logical Observation Identifiers Names and Codes (LOINC) section identifiers:

SOAP Component	Core Clinical Content (StatPearls / POMR Standard)	Primary LOINC Section Code(s)	HL7 FHIR R4 Resource Mapping
Subjective (S)	Chief Complaint (CC), History of Present Illness (HPI: onset, location, duration, character, alleviating/aggravating factors, radiation, timing, severity), PMH/PSH, medications, allergies, Review of Systems (ROS)	10154-3 (Chief Complaint) 10164-2 (History of Present Illness) 10187-3 (Review of Systems)	Condition (problem-list items), MedicationStatement, AllergyIntolerance, Composition.section
Objective (O)	Vital signs (BP, HR, RR, Temp, SpO2, BMI), physical examination by organ system, laboratory results, pathology, and imaging reports	8716-3 (Vital Signs) 29545-1 (Physical Findings) 30954-2 (Relevant Diagnostic Tests/Lab Data)	Observation (vital-signs and laboratory profiles), DiagnosticReport
Assessment (A)	Synthesis of S and O findings, working diagnosis or ICD-10-CM coded problem status (improved, stable, worsening), and ranked differential diagnosis rationale	51848-0 (Evaluation Note / Assessment) 51847-2 (Assessment and Plan combined section)	ClinicalImpression, Condition (encounter-diagnosis)
Plan (P)	Diagnostic workup ordered, therapeutic changes, specialist consultations, patient/participant safety instructions, and follow-up interval	18776-5 (Plan of Care Note)	CarePlan, ServiceRequest, MedicationRequest, Appointment

Reusable Blank SOAP Note Template

Clinicians, clinical research coordinators, and health-informatics designers can adapt the structured template below for outpatient progress notes, simulation training, or clinical trial source-document worksheets (ensuring ALCOA+ data integrity attribution and contemporaneous timestamps):

ENCOUNTER METADATA
Date / Time of Encounter: [YYYY-MM-DD HH:MM Timezone]
Patient / Participant ID: [Identifier]   Visit Type: [Outpatient / Telehealth / Study Visit #]
Author / Role / Credential: [Name, Credential]

S — SUBJECTIVE
Chief Complaint (CC): "[Patient's primary concern in their own words]" for [duration].
History of Present Illness (HPI - OLD CARTS):
  - Onset: [When symptoms began and context]
  - Location / Radiation: [Anatomical site and spread]
  - Duration / Timing: [Constant vs. intermittent, frequency]
  - Character: [Quality of symptom, e.g., aching, sharp, throbbing]
  - Aggravating / Alleviating Factors: [What worsens or relieves symptoms]
  - Severity: [0-10 numeric rating scale or functional impact]
Relevant Past Medical / Surgical / Family / Social History: [Pertinent background]
Current Medications & Adherence: [Reconciled list and reported adherence]
Allergies: [Agent and documented reaction]
Pertinent Review of Systems (ROS): [Positive and negative symptoms by system]

O — OBJECTIVE
Vital Signs: BP [mmHg] | HR [bpm] | RR [breaths/min] | Temp [°C/°F] | SpO2 [%] | Wt [kg]
General Appearance: [Alertness, distress level, orientation]
Targeted Physical Examination:
  - [System 1, e.g., Cardiovascular]: [Inspection, palpation, auscultation findings]
  - [System 2, e.g., Respiratory]: [Effort, breath sounds]
  - [System 3, e.g., Musculoskeletal / Neurologic]: [Range of motion, strength, focal deficits]
Diagnostic & Laboratory Data Reviewed:
  - [Lab / Point-of-Care / Imaging test name, date, and verified result]

A — ASSESSMENT
 Summary Statement: [Age]-year-old [sex/gender] with [relevant history] presenting with [key S/O synthesis].
Problem List & Differential Diagnosis:
  1. [Primary Diagnosis / Problem #1 (ICD-10-CM code if applicable)] — [Status: new / stable / worsening; clinical reasoning and ruled-out differentials]
  2. [Secondary Comorbidity / Problem #2] — [Current control status]

P — PLAN (Organized by Problem)
Problem #1: [Diagnosis Name]
  - Diagnostics Ordered: [Labs, imaging, or protocol assessments]
  - Therapeutics / Interventions: [Continued or modified management plan]
  - Patient Education & Safety Net: [Warning signs discussed and patient understanding confirmed]
  - Follow-Up / Disposition: [Next visit interval, specialist referral, or study visit window]

Clinician Signature / Electronic Attestation: [Signed & Timestamped]

Worked SOAP Note Example (Fictional Illustrative Encounter)

The following filled SOAP note example uses entirely fictional patient details to illustrate how Subjective reports, Objective measurements, Assessment reasoning, and Problem-indexed Plan items fit together in an outpatient clinical research follow-up visit.

ENCOUNTER METADATA (FICTIONAL EXAMPLE)
Date / Time: 2026-10-14 09:30 EDT
Participant ID: SUBJ-4029 (Fictional Composite)   Visit: Week 4 Outpatient Follow-Up
Author: J. Rivera, MSN, RN, CCRC / Co-Investigator: A. Patel, MD

S — SUBJECTIVE
Chief Complaint: "My home blood pressure readings have been lower this week, but I felt mildly dizzy standing up yesterday morning."
History of Present Illness: 58-year-old participant with essential hypertension returning for scheduled Week 4 hypertension registry follow-up. Reports home seated blood pressure readings averaging 126/78 mmHg over the past 7 days. Describes a single episode of transient lightheadedness yesterday morning upon rising quickly from bed, lasting approximately 15 seconds and resolving spontaneously after sitting at the edge of the bed. Denies syncope, falls, chest pain, palpitations, dyspnea, headache, or visual changes. Reports full daily adherence to prescribed antihypertensive regimen and increased fluid intake after morning walk.
Allergies: No known drug allergies (NKDA).
Review of Systems:
  - Constitutional: Denies fever, chills, or fatigue.
  - Cardiovascular: Denies chest pressure, orthopnea, or lower-extremity edema.
  - Neurologic: Positive for single brief orthostatic lightheadedness episode; denies vertigo, focal weakness, or numbness.

O — OBJECTIVE
Vital Signs:
  - Seated (after 5 min rest): BP 124/76 mmHg | HR 68 bpm (regular) | RR 14/min | Temp 36.7 °C | SpO2 98% on room air
  - Standing (at 1 min / 3 min): BP 118/74 mmHg, HR 74 bpm (1 min); BP 120/76 mmHg, HR 72 bpm (3 min) — orthostatic vital signs negative (drop < 20 mmHg systolic and < 10 mmHg diastolic); participant asymptomatic during standing test.
Physical Examination:
  - General: Alert, oriented ×4, in no acute distress.
  - Cardiovascular: Regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops; peripheral pulses 2+ bilaterally; no pedal edema.
  - Lungs: Clear to auscultation bilaterally throughout all lung fields.
  - Neurologic: Cranial nerves II-XII intact; gait steady; Romberg negative.
Laboratory Data Reviewed (Collected 2026-10-12):
  - Basic Metabolic Panel: Sodium 139 mEq/L, Potassium 4.2 mEq/L, Creatinine 0.92 mg/dL, eGFR > 60 mL/min/1.73m² (all within reference range).

A — ASSESSMENT
58-year-old participant with essential hypertension at blood pressure target (124/76 mmHg) on current regimen, presenting with a single self-limited episode of morning postural lightheadedness without objective orthostatic hypotension on today's seated-to-standing evaluation.
  1. Essential hypertension (I10) — Controlled; target blood pressure achieved with normal renal function and electrolytes.
  2. Transient postural lightheadedness (R42) — Resolved; negative orthostatic blood pressure and heart-rate criteria in clinic; likely related to rapid morning arising and mild overnight volume depletion rather than persistent autonomic or medication-induced orthostasis.

P — PLAN
1. Essential Hypertension:
  - Continue current antihypertensive regimen without change.
  - Continue twice-daily standardized home blood pressure log via study portal.
2. Transient Postural Lightheadedness:
  - Diagnostic: Orthostatic vitals verified negative in clinic today; BMP electrolytes normal.
  - Education: Reviewed gradual position changes when rising from supine to sitting to standing in the morning and maintaining adequate daytime hydration.
  - Safety Net: Instructed participant to contact the clinic immediately or seek urgent evaluation if recurrent dizziness, near-syncope, syncope, chest pain, or home systolic BP < 100 mmHg occurs.
  - Follow-Up: Return for scheduled Week 8 visit, with telephone check-in by coordinator in 7 days.

Electronically Signed: A. Patel, MD — 2026-10-14 09:58 EDT

Required Elements Checklist for Clinical Quality and Research Audits

Whether reviewing a SOAP note for CMS Evaluation and Management (E/M) documentation compliance or Good Clinical Practice (ICH E6) source-data verification, use this 8-point checklist to prevent common documentation defects:

1. Clear Separation of S vs. O: Patient-reported historical statements belong exclusively in Subjective; clinician-measured vitals, physical exam findings, and verified lab values belong exclusively in Objective. Never record a patient’s unverified home report as an Objective clinic measurement without attributing it.
2. Chief Complaint and HPI Completeness: The Subjective section states a clear reason for the encounter and characterizes symptom dimensions (onset, duration, context, severity) pertinent to clinical decision making.
3. Reconciled Objective Baselines: Vital signs include units of measure and measurement conditions (e.g., seated vs. standing, room air vs. supplemental oxygen), and laboratory/imaging entries state the test date.
4. Internal Consistency Across Sections: Every new diagnosis or problem addressed in the Assessment must be supported by corresponding history in Subjective and/or findings in Objective (preventing “orphan” diagnoses introduced only in billing codes).
5. Problem-Indexed Plan: Every active problem listed in the Assessment has a matching action item in the Plan (diagnostics, therapeutics, monitoring, or disposition).
6. Copy-Forward (Note Bloat) Prevention: Under CMS E/M guidelines and clinical research audit rules, copied-and-pasted physical exam blocks or outdated review-of-systems templates that contradict the current visit’s HPI create severe medical-legal and audit discrepancies. Verify that every carried-forward element was actually performed or confirmed on the date of service.
7. Explicit Medical Decision Making (MDM) or Time: Per CMS Evaluation and Management guidelines, office/outpatient E/M code selection rests on either total clinician time on the encounter date or Medical Decision Making across three elements: (a) number and complexity of problems addressed, (b) amount and/or complexity of data reviewed and analyzed, and (c) risk of complications and/or morbidity or mortality of patient management.
8. Contemporaneous Attribution (ALCOA+): Every note records the author’s full identity, credential, encounter timestamp, and signature timestamp, with any subsequent addendum entered as a dated, signed amendment rather than overwriting original source text.

Frequently Asked Questions

What does SOAP note stand for?

SOAP stands for Subjective, Objective, Assessment, and Plan. Introduced by physician Lawrence L. Weed in 1968 as part of the Problem-Oriented Medical Record (POMR), the acronym defines the four sequential sections of a clinical progress note: patient-reported symptoms and history (Subjective), measurable exam and diagnostic findings (Objective), diagnostic synthesis and differential diagnosis (Assessment), and diagnostic, therapeutic, and follow-up actions (Plan).

What is a SOAP note and how is it used in healthcare and clinical research?

A SOAP note is a standardized clinical documentation template used by physicians, nurses, pharmacists, allied health clinicians, and clinical trial investigators to record patient encounters in a structured, auditable sequence. In electronic health records (EHRs) and clinical research source documentation, SOAP sections map to standardized LOINC clinical note section codes within HL7 C-CDA Progress Notes and FHIR Composition resources, enabling consistent clinical data abstraction, quality measurement, and regulatory source-data verification.

What is the difference between the Subjective and Objective sections of a SOAP note?

The Subjective section records information reported by the patient or caregiver—such as the chief complaint, symptom onset, pain rating, and review of systems—which reflects the patient’s experience rather than direct clinician measurement. The Objective section records verifiable, reproducible findings measured or observed directly during the encounter, including vital signs, physical examination maneuvers, laboratory assay values, and diagnostic imaging results.

Sources

• Podder V, Lew V, Ghassemzadeh S. SOAP Notes. StatPearls, National Center for Biotechnology Information (NCBI Bookshelf) — https://www.ncbi.nlm.nih.gov/books/NBK482263/
• Weed LL. “Medical Records that Guide and Teach.” New England Journal of Medicine (1968; 278:593–600, 652–657) — https://www.nejm.org/doi/full/10.1056/NEJM196803142781105
• Regenstrief Institute — LOINC Clinical Document and Section Codes (10164-2, 10187-3, 29545-1, 51848-0, 18776-5)
• HL7 International — HL7 FHIR US Core Clinical Notes Guidance and DocumentReference Profile
• Centers for Medicare & Medicaid Services (CMS) — Medicare Learning Network Evaluation and Management (E/M) Services Guide