SOAP progress note template

The four components are Subjective (patient’s reported symptoms, feelings, and history), Objective (measurable, observable data like vital signs and examination findings), Assessment (your professional analysis and diagnosis), and Plan (treatment recommendations, follow-up instructions, and referrals). Each section serves a specific purpose in creating comprehensive clinical documentation.

A well-written SOAP progress note typically ranges from half a page to one full page, depending on the complexity of the patient’s condition. Focus on quality over quantity—include essential details without unnecessary elaboration. The goal is to create clear, concise documentation that captures relevant information while remaining readable for other healthcare providers.

Use structured templates with pre-populated sections to guide your documentation process. Focus on relevant clinical information, avoid repetition, and consider using approved abbreviations where appropriate. Document during or immediately after the patient encounter when details are fresh. Remember that quality documentation supports both patient care and reimbursement requirements.

The assessment section should synthesize information from both subjective and objective sections to provide your clinical impression or diagnosis. Include your reasoning for the diagnosis, differential diagnoses if applicable, and the patient’s progress compared to previous visits. This section demonstrates your clinical judgment and understanding of the patient’s condition.