Physician Assistant: Step-by-Step Guide on How to Write SOAP Notes

SOAP notes are essential for effective patient care and documentation in the physician assistant profession. This guide provides detailed instructions for each section of a SOAP note, helping you understand the structure and content required for thorough documentation in the physician assistant context. By mastering SOAP notes, you can enhance patient care, ensure effective communication among healthcare providers, and maintain accurate medical records.

Subjective Section (S)

In a physician assistant SOAP note, the Subjective section (S) captures the patient’s self-reported information about their condition and symptoms. This section provides context for the healthcare provider to understand the patient’s perspective and experiences. Here are the specific things that should go into the Subjective section of a physician assistant SOAP note:

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason the patient is seeking medical attention.
   • Example: "I have been experiencing a persistent cough for the past week."

2. History of Present Illness:

   • Details about the onset, duration, and progression of the current condition.
   • Example: "The cough started suddenly and has been getting worse over the past few days. It is accompanied by a sore throat and mild fever."

3. Associated Symptoms:

   • Any other symptoms the patient is experiencing that may be related to the chief complaint.
   • Example: "The patient also reports fatigue and occasional headaches."

4. Past Medical History:

   • Relevant past medical conditions, surgeries, or hospitalizations.
   • Example: "The patient has a history of asthma and seasonal allergies."

5. Medications:

   • Current medications the patient is taking, including dosage and frequency.
   • Example: "The patient is currently taking albuterol as needed for asthma."

6. Allergies:

   • Any known allergies, including drug, food, and environmental allergies.
   • Example: "The patient is allergic to penicillin."

7. Social History:

   • Information about the patient’s lifestyle, occupation, and habits.
   • Example: "The patient is a non-smoker and works as a teacher."

8. Family History:

   • Relevant medical history of immediate family members.
   • Example: "The patient’s mother has a history of hypertension."

9. Review of Systems:

   • A systematic review of other body systems to identify any additional symptoms.
   • Example: "The patient denies chest pain, shortness of breath, or gastrointestinal symptoms."

Tips:

• Use the patient’s own words when possible.
• Be thorough in gathering information to provide a complete picture of the patient’s condition.
• Ask open-ended questions to encourage detailed responses.

Example of a Subjective Section for Physician Assistant

Objective Section (O)

In a physician assistant SOAP note, the Objective section (O) captures measurable, observable, and factual data obtained during the patient’s examination. This section provides concrete evidence of the patient’s condition and progress. Here are the specific things that should go into the Objective section of a physician assistant SOAP note:

Objective Section (O) Components

1. Vital Signs:

   • Record the patient’s vital signs such as blood pressure, heart rate, respiratory rate, and temperature.
   • Example: "BP 130/85, HR 78, RR 18, Temp 100.4°F"

2. Physical Examination Findings:

   • Document the results of your physical examination, including inspection, palpation, auscultation, and percussion.
   • Example: "Lungs: Bilateral wheezing noted. Throat: Erythema and mild swelling."

3. Laboratory and Diagnostic Test Results:

   • Include results of any lab tests or diagnostic imaging performed.
   • Example: "Rapid strep test: Negative. Chest X-ray: No acute findings."

4. General Appearance:

   • Describe the patient’s general appearance and demeanor.
   • Example: "The patient appears fatigued but in no acute distress."

5. Other Objective Data:

   • Any other relevant objective findings.
   • Example: "Oxygen saturation: 96% on room air."

Tips:

• Be precise and factual in your documentation.
• Include only measurable and observable data.
• Use standardized scales and measurements where applicable.

Example of an Objective Section for Physician Assistant

Assessment Section (A)

In a physician assistant SOAP note, the Assessment section (A) synthesizes the information gathered in the Subjective and Objective sections to provide a clinical judgment about the patient’s condition. This section includes the healthcare provider's professional interpretation, diagnosis, and the patient’s progress and response to treatment. Here are the specific things that should go into the Assessment section of a physician assistant SOAP note:

Assessment Section (A) Components

1. Diagnosis:

   • Provide a clinical diagnosis based on the subjective and objective findings.
   • Example: "Acute bronchitis."

2. Differential Diagnosis:

   • List other potential diagnoses that were considered and ruled out.
   • Example: "Differential diagnosis includes viral upper respiratory infection and asthma exacerbation."

3. Clinical Impression:

   • Include your clinical interpretation of the patient’s condition.
   • Example: "The patient’s symptoms and physical exam findings are consistent with acute bronchitis."

4. Patient Progress:

   • Comment on the patient’s progress since the last visit, if applicable.
   • Example: "The patient reports no significant improvement in symptoms since the last visit."

5. Prognosis:

   • Provide an outlook on the patient’s recovery based on their condition and response to treatment.
   • Example: "The prognosis is good with appropriate treatment and follow-up."

6. Goals:

   • Set specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient’s treatment.
   • Example: "Short-term goal: Reduce cough and fever within one week. Long-term goal: Complete resolution of symptoms within two weeks."

Tips:

• Be clear and concise in your clinical judgment.
• Use evidence-based reasoning to support your diagnosis and clinical impression.
• Set realistic and measurable goals for the patient.

Example of an Assessment Section for Physician Assistant

Plan Section (P)

Plan Section (P) Components

1. Treatment Plan:

   • Specific interventions that will be implemented to address the patient’s condition.
   • Example: "Prescribe a course of antibiotics if bacterial infection is suspected."

2. Medications:

   • Detailed description of any medications prescribed, including dosage and frequency.
   • Example: "Prescribe azithromycin 250mg, take two tablets on day one, then one tablet daily for the next four days."

3. Diagnostic Tests:

   • Any additional tests that need to be performed to further evaluate the patient’s condition.
   • Example: "Order a complete blood count (CBC) to rule out bacterial infection."

4. Patient Education:

   • Information and instructions provided to the patient to help them manage their condition and prevent further illness.
   • Example: "Advise the patient to stay hydrated, rest, and use a humidifier to ease coughing."

5. Follow-Up:

   • The plan for subsequent visits, including the frequency and duration of follow-up appointments.
   • Example: "Schedule a follow-up appointment in one week to reassess symptoms and response to treatment."

6. Referrals:

   • Any referrals to other healthcare professionals or specialists if necessary.
   • Example: "Refer the patient to a pulmonologist if symptoms do not improve with initial treatment."

Tips:

• Be specific and detailed in your treatment plan to ensure clarity and adherence.
• Tailor the plan to the individual needs and goals of the patient.
• Ensure that the patient understands their role in the treatment plan, especially for home care and medication adherence.

Example of a Plan Section for Physician Assistant

This detailed information in the Plan section ensures that the patient receives a comprehensive and personalized treatment strategy, and helps track progress and outcomes effectively.