How SOAP Notes Help You Think Like a Doctor

If you want to work in healthcare, you need more than science knowledge, you need clinical reasoning. That means learning how to think like a doctor: ask the right questions, spot important clues, and decide what to do next.

One of the first tools medical professionals learn is called a SOAP note. It’s a simple, powerful way to organize information about a patient.

What is SOAP?

SOAP is a four-part format used to write down what’s going on with a patient during a medical visit. It’s used by doctors, nurses, EMTs, and even students in training.

Each letter stands for a key step:

√ S – Subjective

What the patient tells youThis includes:

• Their symptoms (what they feel)

• When the problem started

• How bad it is

• What makes it better or worse

• Their medical history and lifestyle

Example: “My stomach has been hurting for 2 days. It’s worse when I walk.”

√ O – Objective

What you observe or measureThis includes:

• Vital signs (like temperature, heart rate, blood pressure)

• Physical exam results

• Lab tests or scans

• Anything you can see or confirm

Example: “Temp: 100.9°F. Tenderness in lower right abdomen.”

√ A – Assessment

What you think is happeningThis is your diagnosis — or a list of possible causes (called a differential diagnosis). You base this on the facts from S and O.

Example: “Most likely appendicitis. Other possibilities: ovarian cyst, stomach virus.”

√ P – Plan

What you’ll do nextThis is your treatment or next steps. It can include:

• Tests or imaging

• Medication

• Procedures

• Follow-up instructions

• Referrals to specialists

Example: “Order ultrasound and CBC. Keep patient NPO. Start IV fluids. Surgical consult.”

Why SOAP Notes Matter

SOAP notes help future health professionals:

• Stay organized

• Think logically

• Communicate clearly with other team members

• Solve real-life medical problems

They’re not just paperwork; they reflect how doctors think, reason, and care for patients.

Sample SOAP Note (Abdominal Pain)

Chief Complaint: Lower right belly pain

S – “Patient reports sharp pain in the lower right abdomen for 2 days.No vomiting. Pain gets worse with movement. Rates it 7 out of 10.”

O – Temp 100.9°F, HR 95 bpm, tenderness on palpation in right lower quadrant.

A – Likely appendicitis. Rule out ovarian torsion or GI infection.

P – Order CBC and abdominal ultrasound. NPO. IV fluids. Surgical consult.

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