This document explains the SOAP documentation method used by healthcare providers to organize patient information, consisting of four sections: Subjective, Objective, Assessment, and Plan. Each section has specific guidelines for documenting patient conditions, progress, and future management plans concisely and accurately. The document also includes reminders on writing style and references for further reading on SOAP notes.

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How to prepare
SOAP cases
Alaa Fadhel Hassan(MSc. Pharm)
Drug Information Centre
Al-Mahmoudiya general hospital

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SOAP CASE, Wait what is this?!!!

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What is SOAP
SOAP—or subjective, objective,
assessment and plan- a
documentation method helps
health care provider documenting
pt. information in an organized
way, starting from history ending
with clinical decision development

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Subjective
 A short section; 2-3 sentence, that describe pt.
subjective conditions (non-measured values) ex.
complains affecting his quality of life, what he feels or
say,
(stick to the pt. expression & avoid own
assessment , reasoning or intervention).
 Summary: observed, obtained, descriptive &
confirmed by diagnostic test/procedure.

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Subjective

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Objective
 A compromised section include measurable, factual &
objective pt. information's like his/her daily
performance information & quotes, i.e document the
information's that allow tracking pt. progression
depending on medical setting/ measurements, if the
goals were met fully, partially or not met at all
 Summary: Observed, measured & verified by
health care provider.

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Objective

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Assessment
 (This section should be the meat of the SOAP note -
Its a narrative of what actually happened during the
session). A 1-2 sentence include pt. identifiers like
age, medical/medication history, diagnosis
confirmed/differential, prognosis of pt. if any
improvement took place
 Summary: The problem diagnosis/differential
diagnosis, solutions & evidence.

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Assessment

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Plan
 Section summarize the future plan starting from
enlisting pt. problems (all of them0 with management
plan for each one.
 Summary: additional diagnosis test/ revising
treatment - change or cessation toward specified
goals (short versus long term goals plan as
eliminate disease & prevent recurrence.

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Plan

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Plan, ex.

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Remember when writing SOAP
Do: Be concise,
Be specific,
Write in the past tense
Don’t: Make general statements,
Use words like “seem” & “appear”

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References
 Kunal Sindhu. What are SOAP notes?. Wolterskluwer. March 2020.
https://www.wolterskluwer.com/en/expert-insights/what-are-soap-notes
 University of Vermont Graduate Writing Center SOAP Notes: A Writer’s Guide
https://www.uvm.edu/sites/default/files/Graduate-Writing-
Center/GWC%20Guides/Genres/SOAP_Notes_101.pdf
 Lenyta Oliveira Gomes, Marina Raijche Mattozo Rover, Aline Aparecida Foppa,
Rosana Isabel dos Santos, Silvana Nair Leite, Mareni Rocha Farias. The clinical
pharmacist’s role in a high-cost medicine pharmacy: Patient-centered care. Braz.
J. Pharm. Sci. 2022;58: e20301.
https://www.scielo.br/j/bjps/a/xFkL84gPh9yKfrDdH9FfpxF/?format=pdf&lang=en
 Gouhar Sultana. Pharmaceutical care plan SOAP notes. G.Pulla Reddy College
of Pharmacy,Hyderabad
http://gprcp.ac.in/econtents/Gouhar%20%20Pharmaceutical%20Care%20plan.p
df

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