Accurate and organized clinical documentation is essential for effective patient care. Two of the most commonly used note formats are SOAP and DAP notes, which provide a structured method for recording patient interactions.
In this article, we’ll break down the SOAP note format, provide an example, compare it to other documentation styles like the DAP note, and offer tips for improving your clinical notes.
Understanding the SOAP Note Structure
SOAP notes follow a four-part structure:
- Subjective (S) – The patient’s reported symptoms, concerns, and medical history in their own words.
- Objective (O) – Measurable data, such as vital signs, physical exam findings, and test results.
- Assessment (A) – The clinician’s diagnosis or interpretation based on subjective and objective findings.
- Plan (P) – The next steps for treatment, including medications, tests, follow-ups, or referrals.
[Very Short] SOAP Note Example
Patient Name: Jane Doe
Date: 03/10/2025
Provider: Dr. Smith
S: Patient reports a persistent cough for two weeks, describing it as dry and worsening at night. She denies fever or chest pain but mentions mild fatigue.
O: Temp: 98.6°F, BP: 120/80 mmHg, HR: 72 bpm, RR: 16 bpm. Lungs clear to auscultation; no wheezing or rales. No signs of respiratory distress.
A: Likely viral upper respiratory infection. No evidence of pneumonia or other complications.
P: Increase fluid intake, rest, and use over-the-counter cough suppressant as needed. Re-evaluate in one week if symptoms persist.
[Longer] SOAP Note Example
Patient Name: Jane Doe
Date: 03/10/2025
Provider: Dr. Smith
Subjective:
Chief Complaint (CC): Persistent cough x two weeks
History of Present Illness (HPI): Patient ℅ persistent cough last two weeks. Patient states that the “cough is dry and worsening at night”. Patient reports the cough started “after a short cold lasting two days”. She denies fever or chest pain but mentions having mild fatigue.
Past Medical History (PMH):
- Allergies: NKA
- Current Medications: Loratadine 10mg QD
- Immunizations: UTD
Objective:
Vital Signs: Temp: 98.6°F, BP: 120/80 mmHg, HR: 72 bpm, RR: 16 bpm.
Physical Exam
General Demeanor: Comfortable; Development: Well-developed, Well Nourished, No Distress
HEENT
Skull: Normocephalic, Auditory Canal: Normal; Tympanic Membrane: Normal
Eyeball, Sclera, and Conjuctiva: Normal ; Pupil and Lens: PERL, Discharge: Watery Discharge; Sinuses: Frontal Sinuses Normal, Maxillary Sinuses Tender
Oral Cavity: Normal; Soft & Hard Palate: Normal; Tonsils and adenoids: Normal; pharynx:normal BL submandibular shotty lymphadenopathy, ttp
Cardiovascular
Rhythm/Rate: Regular Rate/Regular Rhythm; Heart Sounds: Normal S1/S2 Heart Sounds
Respiratory
Breathing: Normal Breath Sounds: Normal
Neurological
Orientation: x3; Thought Content/Perception: Normal; Cognitive Function: Normal
Skin
Moisture/Temperature: Normal, Dry
Psychiatric
Behavior: Normal, Mood and Affect: Normal, Judgement and Thought Content: Normal
Skin
Moisture/Temperature: Normal; Body, Hair, Mobility & Tugor: Normal Tugor
Capillary refill <2 Seconds
Assessment:
Patient with hx of common cold. Clinical exam suggests likely viral upper respiratory infection. No evidence of pneumonia or complications.
Plan:
Increase fluid intake, rest, and use over-the counter cough suppressant as needed. Re-evaluate in one week if symptoms persist. Go directly to the ER for any new or worsening symptoms- trouble breathing, chest pain, unusual or severe headache, sudden confusion or change in mental status, coughing or throwing up blood, skin hives from an allergic reaction, seizures, facial drooping, slurred speech, or fever of >100.4F unresolved with tylenol or ibuprofen.
SOAP vs. DAP Notes: Choosing the Right Format
While SOAP notes are common, other formats like DAP (Data, Assessment, Plan) notes offer a simpler structure.
- DAP notes combine subjective and objective information under “Data,” making them more streamlined.
- Compared to SOAP notes, which as we covered separate subjective and objective details, providing a clearer distinction between patient-reported and measurable findings.
Picking Between SOAP and DAP Notes
When choosing between SOAP and DAP notes, practitioners should consider their documentation needs, workflow preferences, and the length and complexity of the visit.
- SOAP notes provide a comprehensive and detailed record, making them ideal for lengthy or complex visits that require thorough documentation for initial visits, insurance billing, legal purposes, or continuity of care.
- On the other hand, DAP notes can offer a more streamlined approach, reducing redundancy and saving time while still capturing essential patient information. They tend to be commonly used for follow-up visits, lab consultations, injections or therapy sessions.
- For shorter or less complex visits, DAP notes may be more efficient, while SOAP notes may be the better choice for cases requiring more structured documentation and clinical reasoning.
How to Write Effective SOAP (and DAP) Notes
Writing an effective SOAP note involves gathering relevant information and structuring it clearly.
- Start with a thorough patient interview to capture subjective details. Pull in your patient submitted intake forms - custom questionnaires and scales - to get a full view of what is happening with your patient.
- Next, conduct a physical examination and record objective findings.
- In the assessment section, analyze the information to form a diagnosis or clinical impression.
- Finally, develop a treatment plan with actionable steps, ensuring it is specific and includes follow-up instructions that your patients will be able to take with them and act upon.
From a documentation standpoint - keeping notes concise, structured, and clinically relevant enhances their usefulness for patient care.
Tips for Writing SOAP Notes
- Be Clear and Concise – Avoid unnecessary details and focus on relevant patient information.
- Use Objective Language – Stick to factual descriptions rather than opinions.
- Maintain Consistency – Follow the SOAP structure to ensure easy readability and continuity of care; templates can help you structure the time and make sure you’re covering all the salient points.
- Incorporate Clinical Judgment – Ensure the Assessment section reflects a clear interpretation of findings; add and update your diagnosis codes consistently.
- Update the Plan Regularly – Use plan templates to quickly generate a comprehensive plan for your patient. Continue to modify the treatment plan based on patient progress and follow-ups.
TIP: Using additional charting sections like Vitals to create more structure around your charting template and chart changes over time
How OptiMantra Helps Simplify Your SOAP and DAP Notes
SOAP and DAP notes provide a standardized approach to clinical documentation, improving communication and patient care. Implementing best practices in note-taking ensures accuracy, efficiency, and better patient outcomes.
In OptiMantra, we offer both SOAP and DAP notes (which we refer to as the Basic Note).
We also have four types of charting templates you can use with either note format to facilitate quicker note-taking - and a very robust library of existing charting templates that you can pull from, but more on that below.
There are four types of charting templates:
- SOAP Templates (Text-based)
- This template allows you to copy whole paragraph(s), with or without fill in the blanks, as macros to speed up your charting.
- Categorized Clickable Templates -
- This type of template allows you to create sentences on the fly using predefined choices - you can quickly click your selections to automatically have them populate into your chart.
- @ (Dot)-Phrase Templates -
- This template allows you to pull from a pre-existing content library of charting templates by typing in an “@” and the phrase title from anywhere in the chart note
- Fun fact - in OptiMantra, you can also use dot/@-phrases in other parts of the program like patient portal messaging and Tasks, email templates, and the Send Records feature to quickly complete every day workflows - so the dot-phrases are very versatile!
- Annotatable Images -
- This template allows you to pull annotatable images directly to your charts (use our existing image library or add your own); you can also annotate directly on patient images to capture your injections, treatments and more
- Plus, Other Charting Shortcuts
- In addition to the charting templates, OptiMantra has other shortcuts like our #diag and #meds to pull up details from the patients chart and quickly insert them it into the chart note
- And, Add Tags which allow you to custom-tag your chart notes to quickly later search e.g., for all your Pelvic Therapy visits or all your Botox charts.
The great news is that you can use just one of these charting templates, or multiple types of templates together. For each of these charting templates, we also have thousands of templates that you can easily choose from and import directly into your account (to edit and adjust as needed). Across any modality - psychiatry, aesthetics, direct and primary care, integrative medicine, or services types (like lasers, cold plunge, etc.) - you can always reference and pull from this resource library at any point.
OptiMantra’s comprehensive EMR and practice management software, has SOAP templates built right into the platform and AI charting! Want to take a look at them? Try our free 15 day trial.
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