Although it is key to the third year, the SOAP format is not taught to most second year students, and the housestaff often forget this.  SOAP stands for subjective, objective, assessment, and plan.  The SOAP note is a daily progress report in the patient's chart, and so it is different from the comprehensive admit note you learned to write in physical diagnosis. The instructions below should give you a general idea of what information to include and where.  Many of the particulars of your notes will be different for each rotation, so be sure to get feedback from your housestaff about your notes as early as possible, and adjust your style accordingly.As the name implies, a progress note sums up the progress that has been made in the patient’s care since the last note.

The progress note should express the following:

(1) Are there any changes in the patient’s symptoms and complaints
(2) What is the current physical exam, are there any changes from your prior note?
(2) Report new lab data and results of studies
(3) What is the current formulation and plan for the patient

Remember, the SOAP note is not supposed to be as complete as an admit note.  Complete sentences are not necessary and abbreviations are appropriate. However, avoid them until you have a handle on how the abbreviations are used - they differ for each specialty, and are consistent within.  The length of the note will differ for each specialty as well.  Generally, surgical notes are short and medical notes are long, but you will have to get a sense of what to do from your housestaff.  Remember that the medical student's note (and physical) should always be more detailed than the intern's.  You have less clinical judgment and experience, so you must give a more thorough report of what you observed.

Always keep in mind that the chart is a legal document. Be bold in your presentations, but conservative in the chart.  Also, because it is a legal document, you should start your note right after the last note in the chart so it will be chronological.  For neatness sake you may want to start at the top of a page, so strike out any blank space above your note.  You should also provide room for your residents to amend your note at the end.

While writing your note, do not leave blank lines in between text.  This is to prevent someone else from writing in your note which could be bad for legal reasons.  Similarly, if you make a mistake, simply cross out the word with a single horizontal line, write “error”, and initial it.  Do not scribble out a mistake.  Again, legally speaking, people must be able to see your mistakes and know that you personally crossed the word or sentence out.  Always sign your notes after your printed name and include your beeper number.  Once again, always leave room on the same page for your notes to be amended and cosigned by the resident. Just remember that SOAP notes should be flexible. You will develop your own style, and you should try to accommodate housestaff preferences as this will allow you to experiment with subtle differences in technique.

We have provided examples of a medicine style SOAP note and a surgery style SOAP note so that you can see the difference.  However, it is important to remember that the same basic components are present in each. The medical SOAP note applies to the medicine, pediatrics, and neurology clerkships.  This note, while allowed to be longer than surgery, should generally not exceed one full page.  Obviously, the important components of the progress note will differ depending upon what service you are on.  For example, neurology will require a more complete neurological exam in the progress note than other clerkships.