SOAP Note Examples – Medical Assistant Net #best #online #medical #assistant #programs


SOAP Note Examples for Medical Assistants

A SOAP note is always written in a particular format; its purpose is to record information regarding a specific

patient’s treatment in a consistent manner. The SOAP note format continues to be the format of choice in

ambulatory medical settings. The medical assistant is allowed to write the S-part exactly as stated by the

patient and is allowed to write the O-part exactly as observed into the patient’s record. The medical assistant

is not allowed to write the A-part and not allowed to write the P-part into the patient’s record.

SUBJECTIVE – The initial portion of the SOAP note format consists of subjective observations. These are

symptoms the patient verbally expresses or as stated by an accompanying relative or significant other. These

subjective observations include the patient’s descriptions of pain or discomfort, the presence of nausea or

dizziness, when the problem first started and a multitude of other descriptions of dysfunction, discomfort, or

illness the patient describes.

OBJECTIVE – The next part of the format is the objective observation. These objective observations include

symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective

observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of

ASSESSMENT – Assessment follows the objective observations. Assessment is the diagnosis of the patient’s

condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not

be clear and could include several diagnosis possibilities.

PLAN -The last part of the SOAP note is the health care provider’s plan. The plan may include laboratory

and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g. minor

surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g. home care, bed

rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g.

elevate foot, RTO 1 week), and follow-up directions for the patient.

Example SOAP Note 1:

Patient Name: Roberta Kryle DOB: 12/31/1961 Record No. K-6112r809 Date: 09/09/1999

S-CC: I feel fat . Pt. states that she has always been overweight. She is very frustrated with trying to diet

because she always feels hungry. Her 20 year class reunion is next year and she would like to begin working

toward a weight loss goal that is realistic and within reach. NKDA, NKA.

O-WT = 210 lbs HT = 60� IBW = 115 lbs Chol = 255 BP = 129/75

A-Obese at 183% IBW, hypercholesterolemia

P-Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal:

Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and

smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in three

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