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The SOAP Note and
Presentation
Melanie G. Hagen, MD
Rebecca R. Pauly, MD
University of Florida
Use the SOAP Format for all
Oral Presentations and Notes
z Sometimes the term “SOAP” note is only applied to
short notes but the format is used throughout
medical practice for communication.
z Subjective
z Objective
z Assessment
z Plan
SOAP Notes
z Subjective
z Includes information you have learned from the
patient or people caring for the patient.
SOAP Notes
z Objective
z This section includes observations and
measurements that you have made during the
physical examination.
z Includes the vital signs.
z Includes a general description of the patient.
z Results of diagnostic testing also go here.
z Laboratory results
z Imaging
z Pathology reports
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