Glossary
SOAP note
A SOAP note is a structured clinical note with four parts: Subjective, Objective, Assessment and Plan. The format was developed by Larry Weed, and a StatPearls reference article describes it as a widely used documentation method for clinicians.
Updated October 17, 20262 cited facts, each traced to its source
Also called Subjective, Objective, Assessment, Plan.
A SOAP note is a clinical note divided into four parts: Subjective, Objective, Assessment and Plan. Clinicians use it to record a visit in a fixed order, so a reader can find the same kind of information in every note. The StatPearls reference article on SOAP notes calls it a widely used documentation method for clinicians 1.
Each part answers a different question
| Part | What goes in it | Example line |
|---|---|---|
| Subjective | What the patient reports in their own words | "Three days of sore throat." |
| Objective | What the clinician measures or observes | "Temperature and throat exam recorded." |
| Assessment | The clinician's interpretation of the findings | "Probable viral infection." |
| Plan | The next steps: tests, treatment, referral, follow-up | "Fluids and rest; review in one week if not better." |
The examples are illustrative, not clinical advice. The point of the format is the separation: what the patient said, what was observed, what the clinician concluded, and what happens next.
Where the format came from
The StatPearls article credits Larry Weed with developing the widely adopted SOAP note structure almost 50 years ago 2. The article gives that age as approximate, so read it as a rough date.
A concrete example
A nurse practitioner dictates a follow-up visit. She speaks the four headings in order, as a template prompts her to, and says the patient's symptoms, then the vital signs, then her impression, then the plan. The recognized draft comes out in that same order, and she checks each section before she signs.
Why it matters for dictation and typing
Speaking a note in SOAP order is a practical habit, because the writer always knows which section comes next. A dictation template with the four headings turns the structure into prompts, and the same headings make typed notes quicker to scan.
A note that mixes the plan into the subjective section is harder to check, whether the draft came from dictation, a scribe or a keyboard.
Related terms
- Electronic health record is where SOAP notes are usually stored.
- Medical scribe is the person or tool that often drafts the four sections.
- Dictation template is a reusable layout for the headings.
Guides that cover it
Evidence
Every number on this page, with where it comes from. Open a fact to see the exact words in its source.
- 1.
- 2.
Related terms
- Dictation for Work: Doctors, Lawyers, Writers, StudentsThe topic this term belongs to
- Back-end speech recognitionBack-end speech recognition is a workflow in which the dictated audio is recognized and then edited by someone else, usually a transcriptionist, before it is signed. Its main trade-off is the cost and time of the second pass against the writer's own editing effort.
- CopytakerA copytaker was a typist in a newspaper office who took down stories that reporters dictated over the telephone. The Collins English Dictionary defines the role this way, and it predates the computer-based filing that replaced it.
- Dictation templateA dictation template is a block of text saved under a short spoken phrase, so one phrase inserts the whole block. Dragon calls these auto-texts, and Microsoft's Dragon Medical One guide documents the command that creates one from selected text.
- Electronic health record (EHR)An electronic health record (EHR) is a digital record of a patient's health information, built up over time from visits across care settings. The federal eCQI glossary also calls it an electronic medical record (EMR), and it is where dictated and typed notes end up.
- Front-end speech recognitionFront-end speech recognition is a workflow in which the person who dictates also reviews, corrects and signs the text, instead of passing the audio to someone else. The term is most common in radiology, where it is set against back-end transcription.
- Medical scribeA medical scribe is a person, or more recently an AI tool, that records what happens in a clinical visit and writes it into the chart so the clinician can focus on the patient. The clinician remains responsible for the note and must check and sign it.
- Pajama timePajama time is the record-keeping that clinicians finish after their clinic day ends, often at home in the evening. A 2017 study of primary care clinicians measured 86 minutes of EHR work per weekday after clinic hours.
- Registered Healthcare Documentation Specialist (RHDS)The Registered Healthcare Documentation Specialist (RHDS) is a voluntary credential from AHDI for people who create healthcare documentation. It is awarded after an exam of 120 questions, and it is a prerequisite for the CHDS.
- ScopistA scopist edits the transcripts of official proceedings that court reporters create. Scopists are typically paid by the page, starting from $1.00 to $1.50 per page, and the role is also called transcript editor.
- Transcription line rateA transcription line is a unit of 65 characters, and the line count is the number of such units in a document. The transcription line rate is the price paid for each line, so the unit controls how transcribed work is measured.