Clinical documentation: What is the SOAP format and how do you write a good SOAP note?

The SOAP format organises a clinical encounter into four sections: Subjective, Objective, Assessment, and Plan. It records what the patient said, what the clinician found, what they think is happening, and what happens next. The format is a cognitive aid and a communication tool between members of a care team.

Who developed the SOAP format?

Dr Lawrence Weed, an American physician, developed the SOAP format in the 1960s as part of his Problem-Oriented Medical Record system. Weed argued that clinical records should organise around the patient's problems rather than the clinician's specialty, a break from the narrative, free-text records common at the time.

The format reached the UK through clinicians who encountered Weed's teaching directly. Writing in the British Medical Journal (BMJ), one physician recalled seeing a film of Weed's presentations during registrar training at St Mary's Hospital in the late 1960s, and adopting a scientific approach to case notes as a result. SOAP has since become the dominant standard for encounter-based documentation internationally, though the Chartered Society of Physiotherapy notes that no UK regulator actually mandates its use. Clinicians can choose any structure that captures assessment, advice, and treatment.

What goes in each section of a SOAP note

Subjective records the patient's own account: how they feel, what brought them in, and how long symptoms have lasted. This is the patient's narrative, not the clinician's interpretation of it. It typically covers the presenting complaint, relevant history and medications, and the patient's own concerns.

Objective holds measurable, clinician-recorded data that another clinician could verify: vital signs, examination findings, test results, and observations. The Professional Record Standards Body, working with the Academy of Medical Royal Colleges, sets national standard headings for exactly this kind of content so that records stay consistent across National Health Service (NHS) systems.

Assessment synthesises the Subjective and Objective data into a clinical interpretation, such as a working diagnosis or an evaluation of how a known condition is progressing. The Health and Care Professions Council's own standards require registrants to keep clear, accurate records and to be able to explain the record-keeping decisions they've made, so vague entries such as "patient improving" or "as before" fall short of what the regulator expects.

Plan documents what happens as a result of the assessment: investigations ordered, treatments started, referrals made, and follow-up arrangements. A before-and-after study at Nottingham University Hospitals NHS Trust, published in BMC Health Services Research using the Royal College of Physicians' own audit tool, found persistent gaps in discharge summary completeness, particularly around medication changes, which is exactly the kind of Plan detail another clinician needs to act on safely.

How SOAP compares with other documentation formats

SBAR (Situation, Background, Assessment, Recommendation) suits clinical handovers and urgent communications, favouring brevity over the comprehensive detail SOAP provides. It's the format NHS England recommends for exactly this purpose.

DAP (Data, Assessment, Plan) is a simplified three-section format used mainly in mental health and counselling settings, merging Subjective and Objective into a single "Data" section. APSO reverses the SOAP order, placing Assessment and Plan first, which some inpatient teams prefer when the priority is the management decision rather than the full history.

SOAP remains the most widely used format because it mirrors the natural sequence of clinical reasoning: history, examination, interpretation, action.

Common mistakes in SOAP notes

Two UK audits looked at how well hospital notes met national standards. At University Hospital Crosshouse (NHS Ayrshire and Arran), a review of surgery notes found major gaps — but a new template plus staff training led to big improvements. A similar audit at Broomfield Hospital (Mid and South Essex NHS Foundation Trust) found the same pattern in general surgery ward round notes: poor compliance with basic standards, until targeted changes fixed it.

Across these audits, the most common problems were:

• Mixing sections, such as recording clinical signs under Subjective or symptoms under Objective

• Vague Assessment statements like "patient improving" or "no change," written without clinical justification

• Incomplete Plan entries that omit follow-up arrangements or investigation timelines

• Excessive irrelevant detail, particularly in the Subjective section, that buries clinically significant information

• Delayed documentation, since notes written hours or days later are more likely to contain inaccuracies.

These errors carry legal and regulatory weight as well as clinical risk. Clinical notes are legal documents, and incomplete or inaccurate records can have real consequences during a complaint or investigation.

How SOAP notes support clinical coding and medical record system workflows

When the Assessment section documents a diagnosis using recognised terminology, and the Plan specifies the interventions carried out, coders can map that information to clinical codes such as SNOMED CT or ICD-10 and ICD-11 more accurately. Poor documentation creates downstream problems: coders must interpret ambiguous notes, clinicians get asked to amend records, and billing or reporting data becomes unreliable.

Medical record systems can structure SOAP notes using templates that prompt clinicians to complete each section. A quality improvement project introducing a structured discharge summary template, built on Professional Record Standards Body and Royal College of Physicians guidance, found this improved completeness across every core component tracked, though the scale of improvement varied by setting.

How AI medical assistants helps with SOAP note writing

Ambient voice technology and artificial intelligence, meaning computer systems that can process language and generate text, are changing how clinicians create SOAP notes. Rather than typing during or after a consultation, clinicians can use tools that listen to the encounter and generate a structured note automatically, which the clinician then reviews and approves before it enters the patient record.

NHS England's guidance on AI-enabled ambient scribing describes the potential for reduced administrative burden, more face-to-face time with patients, and improved data quality, and confirms that scaling this technology is an explicit part of the NHS 10-year health plan for England. A survey of 598 GPs working in UK primary care, published in npj Digital Medicine, found that 40% were already using AI scribes, with concerns about safety and medico-legal risk concentrated among non-users.

Limitations apply too. A pilot study at Central and North West London NHS Foundation Trust, published in BJPsych Open, evaluated ambient voice technology in a child and adolescent mental health service and found it reduced documentation burden, while flagging technological limitations as a barrier to wider rollout. Clinician review and sign-off remain essential. These tools support clinical judgement rather than replace it.

Regulatory status is one useful indicator to check during that evaluation.

What to check before using an AI tool for clinical documentation

Clinical notes contain some of the most sensitive personal data that exists, so any artificial intelligence assisted documentation tool needs to meet a high bar. Before adopting one, check:

• General Data Protection Regulation compliance, including a lawful basis for processing and clear retention and deletion policies

• Data residency, confirming the tool processes and stores data within the European Union or European Economic Area

• ISO 27001 certification, an internationally recognised information security standard

• Medical Device Regulation (MDR) status, since some documentation tools may count as a medical device under the European Union's Medical Device Regulation

Don't assume a tool marketed for healthcare automatically meets these standards. Review a vendor's data processing agreement, security certifications, and regulatory status before deploying it in a clinical environment.

Tandem Health's AI Scribe, for example, is certified under the EU Medical Device Regulation as a Class IIa medical device, following independent notified body review, making it the first AI scribe in Europe to reach that classification. That level of certification requires a formal clinical evaluation and an ongoing post-market surveillance system, which gives clinicians and healthcare organisations independent evidence of a tool's safety and performance rather than relying on a vendor's own claims.

Key takeaways for writing better SOAP notes

• Keep sections separate. Record patient-reported information in Subjective and clinician-observed data in Objective.

• Write a specific Assessment. Name the working diagnosis or clinical impression, and document the reasoning behind it.

• Make the Plan actionable. Give another clinician enough detail to act without asking for clarification.

• Document at the time. Notes written promptly are more accurate and more defensible than those completed later.

• Use structured templates where available. They reduce omissions and make data easier to extract for coding and audit.

• Review AI-generated notes carefully. Treat any artificial intelligence drafted note as a starting point that needs clinical review, not a finished document.

The SOAP format has lasted more than six decades because it mirrors how clinicians actually think: gather information, examine the patient, interpret the findings, decide what to do next.

Frequently asked questions

▶ What does SOAP stand for in clinical documentation?

Subjective, Objective, Assessment, and Plan. Subjective is what the patient reports, Objective is what the clinician measures, Assessment is the clinical interpretation, and Plan is what happens next.

▶ Who created SOAP notes and why?

Dr Lawrence Weed, an American physician, developed SOAP in the 1960s as part of his Problem-Oriented Medical Record system, organising notes around the patient's problems rather than the clinician's specialty. It later spread to the UK, where it now sits alongside free-text and hybrid formats.

▶ What's the difference between the Subjective and Objective sections?

The Subjective section records what the patient reports: their symptoms, concerns, and history in their own words. The Objective section records what the clinician observes or measures, such as vital signs, examination findings, and test results. Mixing the two is one of the most common documentation errors, and it undermines the logical structure of the note.

▶ How does SOAP compare to other clinical documentation formats such as SBAR and DAP?

SBAR (Situation, Background, Assessment, Recommendation) suits handovers and urgent communication, and it's the format NHS England recommends for that purpose. DAP (Data, Assessment, Plan) merges Subjective and Objective into one section and is used mainly in mental health. SOAP remains the most widely used format because it mirrors the natural sequence of clinical reasoning.

▶ What are the most common mistakes clinicians make when writing SOAP notes?

Mixing sections, vague Assessment entries such as "patient improving," incomplete Plans, excessive Subjective detail, and delayed documentation. Audits at University Hospital Crosshouse and Broomfield Hospital both found these gaps against GMC and RCS standards.

▶ Are SOAP notes used in the NHS?

Many NHS clinicians use free-text or hybrid formats, and SOAP is more common in private practice, dental care, and allied health. This reflects differences in documentation culture across healthcare systems rather than any limitation of the format itself.

▶ How do SOAP notes support clinical coding?

A clearly documented Assessment and Plan maps more accurately to codes such as SNOMED CT, mandated by NHS England since 2018, or ICD-10/ICD-11. Poor documentation means coders must chase clarification and reporting data becomes unreliable.

▶ How can AI medical assistants help with SOAP note creation?

Ambient voice technology can listen to a consultation and generate a structured SOAP note for the clinician to review and approve. NHS England's guidance frames this as part of the NHS 10-year health plan, and a 2026 survey found 40% of UK GPs were already using AI scribes. Clinician review before the note enters the record remains essential.

▶ What data security and compliance considerations apply to AI-assisted SOAP note tools?

UK GDPR compliance, with guidance from the Information Commissioner's Office; confirmed data residency; ISO 27001 certification; and, where the tool qualifies as a medical device, a UKCA or CE mark from the MHRA. A healthcare marketing claim isn't proof of any of these.

▶ What makes a high-quality SOAP note?

Patient-reported information stays in Subjective, clinician findings in Objective. The Assessment names a working diagnosis with reasoning. The Plan is specific enough to act on without clarification, and written promptly.