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. 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.