How to write a SOAP note that colleagues can use
SOAP stands for Subjective, Objective, Assessment and Plan. It is the most widely taught structure for a clinic note because it separates what the patient told you from what you found and what you decided. Here is what belongs in each part, what to leave out, and a worked example.
Subjective: the patient's account
Start with the presenting complaint in the patient's terms, then the history of that complaint: onset, duration, character, severity, what makes it better or worse, and associated symptoms. Add relevant past history, medicines, allergies and social factors only where they bear on today's problem.
Include pertinent negatives. If you asked about red-flag symptoms and they were absent, say so. A reader cannot tell the difference between a symptom you ruled out and one you never asked about.
Objective: what you measured and saw
Vital signs, examination findings, and any results available at the visit belong here. Write findings as findings, not interpretations: "tender over the medial joint line, no effusion" rather than "knee looks like a meniscal problem".
Keep it proportionate. A focused examination is fine for a focused problem, but document what you examined, including normal findings that matter to the differential.
Assessment: your clinical reasoning
State the working diagnosis or problem, and where it helps, the main alternatives you considered and why you favour one. For a follow-up, say whether the condition is improving, stable or worse compared with last time.
This is the section most often left thin. One or two sentences of reasoning make the plan understandable to the next clinician and to anyone who reviews the chart later.
Plan: what happens next
- Investigations ordered and why.
- Treatment started, changed or stopped, as you decided it.
- Advice given to the patient, including safety-netting: what should prompt them to return sooner.
- Referrals, and the follow-up interval.
Number the plan items if there are several problems, and match them to the assessment so each problem has its own plan.
A short example
S: 34-year-old with 3 days of sore throat and fever. No cough. Able to swallow fluids. No rash. No known drug allergies. O: Temp 38.4. Tonsils enlarged with exudate. Tender anterior cervical nodes. Chest clear. A: Acute tonsillitis, likely bacterial given fever, exudate, tender nodes and absent cough. P: 1. Phenoxymethylpenicillin 500 mg four times daily for 10 days, as prescribed by the treating clinician. 2. Fluids, simple analgesia as needed. 3. Return if unable to swallow fluids, drooling, or worsening after 48 hours. 4. No routine follow-up needed.
Common mistakes
- Copying the previous note forward so old findings look current.
- Mixing the patient's report and your findings in one paragraph.
- An assessment that repeats the complaint instead of stating a diagnosis or problem.
- A plan with no safety-netting or follow-up interval.
- Abbreviations that only you understand.
How ClearPass does it
SOAP is one of the note structures you can pick in ClearPass, alongside Full headings, Follow-up, New patient, Procedure, Problem list and your own headings. Transcribe the visit or type the case, and the draft comes back under the four SOAP headings in English. Choose Concise for key points or Detailed for every clinical fact that was said, then review and paste it into your EMR. See the SOAP note template and a full SOAP note example.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
How long should a SOAP note be?
Long enough that another clinician could pick up the case without calling you. For a simple problem that can be a few lines per heading; complex or multi-problem visits need more.
Where do past medical history and medicines go?
Usually in Subjective, since the patient reports them. Some clinics prefer a separate background section; follow your local convention and be consistent.
Should I write the plan per problem?
Yes, when there is more than one problem. Numbered plan items that line up with the assessment make the note easier to act on.
Is SOAP right for every visit?
It fits most outpatient consultations. Procedures, first visits with long histories and multi-problem reviews are sometimes clearer in a structure built for them, such as a procedure note or a problem list.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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