The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. 

Subjective

This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. 

  • History presenting complaint - SOCRATES.
  • Past Medical history.
  • Medications - current and tried in past.
  • Allergies.
  • Social /occupational history.
  • Review of systems.

Objective

This section documents the objective data from the patient encounter. This includes:

  • Vital signs
  • Physical exam findings
  • Laboratory data
  • Imaging results
  • Review of the documentation of other clinicians.


Assessment

This section documents the combining of “subjective” and “objective” evidence to arrive at a possible diagnosis.  

  • Problem - List the problem/s in order of importance.
  • Differential Diagnosis.


Plan.

  • Further investigation / follow -up.
  • Therapy.
  • Specialist referral.
  • Patient education. Safety net.