Key Takeaways
- SOAP is a way of writing progress notes in a medical chart in four parts: Subjective, Objective, Assessment and Plan.
- SOAP is the progress-note format of the problem-oriented medical record (POMR) described by L. L. Weed in the New England Journal of Medicine in 1968, and it is written for each problem.
- Common mistakes are mixing up the patient's complaints and the physician's findings (S and O), and leaving the Assessment blank or repeating findings there; the Assessment should hold the physician's judgment.
- A SOAP note produced with voice input or AI is a draft; because the physician is responsible for the chart under Article 24 of the Medical Practitioners Act, the physician must review and correct it before finalizing.
"I was told to write in SOAP format, but I am not sure where S ends and O begins." "I don't know what to put in the Assessment." "Our system now builds SOAP notes from voice input — how much should we check?" These questions come up often from physicians who have just started at a clinic, and from medical office staff and clerks who help with charting. This article covers what SOAP means and where it came from, what goes in each part, examples by specialty, common mistakes, and cautions when building SOAP notes from EMR templates or voice input.
Disclaimer: This article is general information based on publicly available information as of October 31, 2026. The examples are fictional and were created for explanation; they do not indicate a diagnosis or treatment plan for any patient or case. Follow the law and your institution's documentation standards for how to write medical records.
What is SOAP?
SOAP is a way of writing progress notes in a medical chart in four parts.
| Part | Term | Meaning | Main content |
|---|---|---|---|
| S | Subjective | Subjective information | Complaints, symptoms, course and daily-life details told by the patient (or family) |
| O | Objective | Objective information | Vital signs, physical findings, test results, imaging findings |
| A | Assessment | Assessment | The physician's judgment based on S and O (diagnosis, differential, severity, evaluation of course) |
| P | Plan | Plan | Tests, treatment, prescriptions, explanations, guidance, next visit |
Separating information (S, O), judgment (A) and action (P) makes it easier for other physicians and staff to follow what the decision was based on, how it was reasoned, and what was done.
How SOAP relates to POS and POMR
SOAP is not a standalone format; it came out of the problem-oriented system (POS).
- POS: an approach that focuses on the patient's problems and organizes care and records by problem
- POMR (problem-oriented medical record): the record format based on POS, made up of a database, a problem list, initial plans, progress notes and so on
- SOAP: the format for progress notes within the POMR
The POMR was set out systematically by the American physician L. L. Weed in "Medical records that guide and teach," published in the New England Journal of Medicine in 1968. In Japan it was introduced by Shigeaki Hinohara and others and spread through medical institutions and nursing.
In the POMR approach, progress notes are written for each problem. The problem list numbers problems such as "#1 Hypertension" and "#2 Dyslipidemia", and the progress notes are written with S, O, A and P under each number. Putting several problems into one SOAP note makes it unclear which assessment belongs to which problem.
The legal basis for what goes in a chart
SOAP is a way of writing; no law requires the SOAP format. The act of keeping a medical record, however, is set by law.
| Source | Content |
|---|---|
| Medical Practitioners Act, Article 24(1) | When a physician provides care, the physician must record matters concerning the care in the medical record without delay |
| Medical Practitioners Act, Article 24(2) | Records of physicians working at a hospital or clinic are kept for five years by its administrator |
| Enforcement Regulations of the Medical Practitioners Act, Article 23 | Items to record: (1) address, name, sex and age of the patient; (2) disease name and main symptoms; (3) treatment (prescriptions and procedures); (4) date of care |
| Rules on Medical Care under Health Insurance, Article 22 | An insurance physician must, without delay, record necessary matters about the care in a medical record in Form No. 1 or an equivalent format |
In insurance-covered care, many billing items require that something be "recorded in the medical record." For example, some medical management fees require the key points of the management to be recorded in the chart. Writing the key points of the guidance and explanations given in the P section makes the billing basis easier to verify later.
What to write in each part, with tips
S (subjective)
What the patient said: chief complaint, onset and course, severity, accompanying symptoms, medication adherence, changes in daily life, worries and wishes.
- Write it close to the patient's own words (for example, "gets short of breath on stairs")
- Information from family or companions also goes in S, with the source noted ("per mother", "per wife")
- Negative statements are important information too ("no chest pain", "no headache")
- Do not mix in the physician's interpretation ("shortness of breath due to heart failure" belongs in A)
O (objective)
Information from examination and tests that anyone checking would find the same.
- Vital signs (temperature, blood pressure, pulse, SpO2, etc.)
- Physical findings (inspection, auscultation, palpation, etc.)
- Test values, imaging findings, test results from other institutions
- Time and conditions of measurement when needed ("office blood pressure", "after rest")
A (assessment)
The physician's judgment based on S and O. It is the most important part of SOAP, and the one most often left blank.
- Diagnosis, or suspected diseases and the differential
- Severity and urgency
- Change since the last visit (better, unchanged, worse) and the reasoning
- Evaluation of treatment effect and side effects
P (plan)
The plan based on A.
- Tests (what, when, why)
- Treatment (continue, change or stop prescriptions; procedures)
- Explanations and guidance given to the patient and family (education plan)
- Next visit, when to come back sooner, whether to refer
Rather than ending P with "observe," write what to observe and what to do if something happens, so the next physician can decide more easily.
SOAP examples by specialty
The following are fictional examples created for explanation. Adjust actual notes to the patient's condition and your institution's documentation standards.
Internal medicine: routine follow-up for hypertension
#1 Hypertension
S: Home BP mostly in the 130s/80s in the morning. No headache or dizziness.
No missed doses. Says she is trying to reduce salt.
O: Office BP 136/84 mmHg (after rest), pulse 72/min, regular.
No leg edema. Home BP diary reviewed.
A: Both home and office BP trending lower than last visit. No symptoms.
Doing well on current treatment.
P: Continue current prescription. Advised to keep recording home BP.
Next visit in 4 weeks; routine blood test planned.
The key is that home blood pressure (the patient's own record) is in S and office blood pressure is in O. Values measured at home are reported by the patient, so they go in S; values measured in the office go in O (the fact that the physician reviewed the home BP diary can go in O).
Pediatrics: fever
#1 Fever
S: Per mother. Fever in the 38s (°C) since last night. Runny nose and cough.
Drinking fluids, urinating as usual. Somewhat fussy.
O: Temp 38.2°C. Active. Mild pharyngeal redness. Clear breath sounds,
no retractions. Good skin turgor.
A: Suspected upper respiratory infection. No findings of dehydration at present.
P: Prescribed symptomatic medication. Explained how to watch the child at home,
and to return if unable to drink, listless, breathing seems difficult,
or the fever continues.
In pediatrics, most of S comes from the parent. Writing "per mother" and recording in P what was told as reasons to return lets staff confirm the background if the family calls at night.
Ophthalmology: red eye and discharge
#1 Right conjunctivitis
S: Redness and discharge in the right eye for 2 days. Mild itching.
No blurred vision. No family members with similar symptoms.
O: VA R (1.2) L (1.2).
Slit lamp: R conjunctival injection, discharge present. Cornea clear.
Anterior chamber clear. L unremarkable.
A: Right conjunctivitis. No corneal abnormality seen.
P: Prescribed eye drops. Advised hand washing and not sharing towels.
Return in 1 week. Come back earlier if vision drops or pain develops.
In ophthalmology, it is especially important to record visual acuity, intraocular pressure and slit-lamp findings in O with right and left clearly stated.
Common mistakes
| Mistake | Example | Fix |
|---|---|---|
| Mixing up S and O | "Has a headache" in O; "pharyngeal redness" in S | What the patient said goes in S; what the physician confirmed goes in O |
| Blank A | Only S, O and P are written | Write the physician's judgment, even in one line |
| A repeats O | A: "BP 136/84" | Write it as an evaluation: "lower than last visit, doing well" |
| P is only "observe" | P: "Observe" | Write what to observe, when to reassess, and what to do if something happens |
| Problems not separated | Hypertension and low back pain in one SOAP | Separate by problem: "#1", "#2" |
| Copying the previous note | Last visit's text left unchanged | Update to what was confirmed today; if nothing changed, say "no change since last visit" |
| Abbreviations only understood in-house | Heavy use of private abbreviations | Agree on an in-house abbreviation list and use nothing else |
The copy-forward function in EMRs is convenient, but it can leave findings that were not actually checked this time. When you copy, always rewrite to match what was confirmed that day.
SOAP in nursing records
SOAP is also widely used in nursing progress notes. The Japanese Nursing Association's "Guidelines on Nursing Records" (2018) state that there are several methods for progress notes, and that each facility should choose a method that records its nursing practice accurately. In nursing SOAP notes, A usually holds the nursing assessment and P the nursing plan.
Cautions when building SOAP from EMR templates or voice input
EMR templates (standard phrases) and features that capture the consultation by voice and draft a SOAP note are now common. They help shorten documentation time, but watch for the following.
Templates
- Are standard phrases such as "no findings" or "normal" being entered for areas that were not actually examined?
- Is every note the same text, hiding changes in each patient?
- Has filling in template fields become the goal, leaving A as a formality?
Voice input and AI drafts
- Misheard numbers: check blood pressure, temperature, test values and drug doses in particular
- Flipped negations: errors that reverse meaning, such as "no chest pain" becoming "chest pain"
- Content the patient never said: symptoms or history added as text that were not in the conversation
- Sorting into S and O: are the patient's words and the physician's findings in the right parts?
- The Assessment: an AI-generated A is only an arrangement of text; the assessment is the physician's judgment, so the physician rewrites or confirms it
Under Article 24 of the Medical Practitioners Act, the physician is responsible for the medical record. Treat SOAP notes produced with voice input or AI as drafts, and set an in-house rule that the physician reviews and corrects them before finalizing. Also confirm, before introduction, how audio data and transcripts are handled (whether they are stored, where, and for what purpose).
Summary
- SOAP is a way of writing progress notes in four parts: S (subjective), O (objective), A (assessment) and P (plan)
- SOAP is the progress-note format of the POMR based on the problem-oriented system, and it is written for each problem
- What the patient or family said goes in S; what was confirmed by examination and tests goes in O. A holds the physician's judgment and should not be left blank
- Do not end P with "observe"; write what to check, when, and what to do if something happens
- SOAP notes from templates, voice input or AI are drafts that the physician reviews and corrects before finalizing
For how SOAP notes are generated from voice and how accurate they are, see How SOAP Notes Are Generated from Consultations; for concrete use in internal medicine, see AI Voice Input for SOAP in Internal Medicine. For differences between voice input methods, see EMR Voice Input Comparison; for an overview of AI EMRs, see What Is an AI EMR?; and for using AI with document templates, see AI Document Creation and Templates.
Pottech provides an AI EMR for clinics that drafts SOAP notes from the consultation for the physician to review and finalize. If you have questions about documentation workload or setting operating rules, please feel free to contact us.
Frequently Asked Questions
- Q. What does SOAP stand for?
- A. Subjective, Objective, Assessment and Plan. S is what the patient said, O is what was found by examination and tests, A is the physician's judgment based on them, and P is the plan going forward.
- Q. How does SOAP relate to POS and POMR?
- A. POS (problem-oriented system) is an approach that organizes care and records around the patient's problems, and POMR (problem-oriented medical record) is the record format based on it. SOAP is the format for progress notes within the POMR.
- Q. Should information from a family member go in S or O?
- A. Information told by a family member or companion goes in S, like the patient's own complaints. Note who gave it, such as 'per mother', so later readers are not misled.
- Q. What goes in the Assessment?
- A. The physician's judgment based on S and O: diagnosis or differential, severity, change since the last visit and evaluation of treatment. Copying the numbers from O is not an assessment.
- Q. Can a SOAP note made with voice input or AI be used as is?
- A. No. The physician should review and correct it before finalizing, because misheard numbers, flipped negations and content the patient never said can occur. The physician is responsible for the chart.
参考・出典
- 医師法（昭和23年法律第201号）第24条 https://laws.e-gov.go.jp/law/323AC0000000201
- 医師法施行規則（昭和23年厚生省令第47号）第23条 https://laws.e-gov.go.jp/law/323M40000100047
- 保険医療機関及び保険医療養担当規則（昭和32年厚生省令第15号）第9条・第22条 https://laws.e-gov.go.jp/law/332M50000100015
- Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278(11):593-600. https://pubmed.ncbi.nlm.nih.gov/5637758/
- 日野原重明「クオリティオブライフとPOS」（第16回日本POS医療学会 特別講演）看護教育 35巻12号, 医学書院, 1994年 https://webview.isho.jp/journal/detail/abs/10.11477/mf.1663900970
- 公益社団法人日本看護協会「看護記録に関する指針」（2018年） https://www.nurse.or.jp/nursing/home/publication/pdf/guideline/nursing_record.pdf