SOAP Note
A SOAP note is a format for writing patient notes. It stands for Subjective, Objective,
Assessment, Plan. It is widely used in the US, and it is also used in the UK in general practice and sometimes when reviewing patients on
the ward.
Outpatient
Inpatient
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Presenting complaint
History of presenting complaint
Systems review
Summary of medical history and medications
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Subjective description of how patient has been since
last review
Explode any symptoms
Objective
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Patient appearance
Vital signs
Physical examination (tailor to complaint)
Test results (lab tests, radiology etc)
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Patient appearance
Vital signs (include any temperature spikes)
In’s and out’s for urine, drains etc
Physical examination (tailor to complaint)
Assessment
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Summary of the clinical problem
Differential diagnosis and clinical reasoning
Plan
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List of investigations/management plans
Safety-net (tell the patient when to re-seek
medical advice)
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Admission day
Antibiotic/post-op day #
Test results (lab tests, radiology etc)
Diagnosis/diagnoses
Problem list
Investigations
Management (including FEN –
fluids/electrolytes/nutrition)
Subjective
07.02.2014 13.45
GP Patient Review (GPST2 Mansbridge)
SUBJECTIVE:
AD is a 38 year old male who presents with tiredness. He has been feeling generally tired for the last 3 months. His fatigue is present
throughout the day but worse on exertion. He sleeps well, usually goes to bed at 10pm and wakes at 7am. He still manages to go to the gym
and play tennis.
On questioning, he also admits to constipation which has also been of 3 months duration. He opens his bowels every 4 days. There is no
blood. He denies any breathlessness, chest pain or abdominal pain. He has note had a fever, night sweats or any weight loss. His mood is
good and he is not stressed at work.
He has a past medical history of asthma. His medications include: Salbutamol inhaler PRN. No allergies.
OBJECTIVE:
AD looks well and comfortable at rest.
T 37˚C, HR 55, BP 120/80, sats 99% RA, RR 15
He has a normal appearance and is clinically euthyroid with no goitre. There is no pallor in the conjunctiva. His chest is clear with normal
heart sounds and abdomen is soft and non-tender. There is no peripheral oedema. There is no palpable lymphadenopathy.
ASSESSMENT:
A 3 month history of tiredness and constipation. Hypothyroidism is possible given his bradycardia and constipation. Anaemia is also possible
but there is no clear source of blood loss. Depression is unlikely given the lack of low mood or anhedonia. There are no signs of infection.
PLAN:
1. Full blood count (r/o anaemia)
2. Thyroid function tests (r/o hypothyroidism)
3. Review in 2 weeks with results
CTN
C. Mansbridge
GPST2
GMC number 7112454
© 2015 Dr Christopher Mansbridge at www.oscestop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision