Progress note — SOAP
The standard medical-record note format: subjective, objective, assessment, plan.
How this document is used well
Write the note as though three readers will see it: a colleague covering for you next week, an auditor, and the patient themselves. In many jurisdictions patients have a statutory right of access to their record, and increasingly they read it. That is a discipline, not a constraint — it discourages speculation, contempt and jargon.
| Section | Contains | Common error |
|---|---|---|
| Subjective | What the patient reported, in their words | Rewriting the patient into clinical language and losing the data |
| Objective | What you observed and measured | Recording inference as observation |
| Assessment | Your clinical thinking, including risk | Omitting reasoning, leaving only conclusions |
| Plan | What happens next, by whom, by when | Vagueness — "continue therapy" |
Complete it
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6 required fields outstanding: Client identifier; S — Subjective; O — Objective …