SOAP note: what goes in each part and how to read a progress note

A SOAP note is a way of writing a progress note so every reader finds the same things in the same place. S is what the patient says. O is what the clinician observes and measures. A is what the clinician concludes. P is what happens next. The order runs from evidence to judgment to action, which is why it has lasted.

The structure comes from the problem-oriented medical record that Lawrence Weed described in 2 articles in the New England Journal of Medicine in 1968, "Medical records that guide and teach." Weed's point was that a chart organized by source (all the labs here, all the nurses' notes there) hides the doctor's reasoning. He proposed a numbered problem list for each patient and a note for each problem that showed the data, the interpretation and the plan. SOAP is the note format that came out of that idea.

Today "SOAP note" and "progress note" are often used as if they meant the same thing. They do not. A progress note is a type of document: the daily or visit-by-visit entry that records how the patient is doing. SOAP is 1 way to structure it. A hospitalist's daily note, a physical therapist's session note, a counselor's visit note and a primary care follow-up can all be progress notes in SOAP form, or in APSO, DAR or narrative form.

Terms you will meet

Progress note

The dated entry that records the patient's course between admission and discharge, or between visits. Physicians, nurse practitioners, physician assistants, nurses and therapists all write them.

Problem list

The numbered list of active and resolved problems. In a problem-oriented note, each assessment and plan maps to a problem on it.

Chief complaint (CC)

A short statement of why the patient is being seen, usually in the patient's own words. It opens the Subjective section.

HPI and ROS

History of present illness and review of systems. The patient's story of the problem and a checklist of symptoms by body system.

MDM

Medical decision making. The billing measure of how complex the Assessment and Plan were.

APSO

The same 4 sections with Assessment and Plan moved to the top.

Addendum

A later entry attached to a signed note, with its own date, time and signature. It adds to the note; it should not replace it.

Copy forward

An EHR function that carries yesterday's text into today's note. Useful for stable history, risky for exam findings and assessments.

The mock note below is a hospital day-2 progress note. The layout is invented; every EHR's note template differs. The 7 marked parts appear on almost all of them.

What belongs in each section

Abbreviations are dense in all 4 sections. "NAD" (no acute distress), "RRR" (regular rate and rhythm), "CTAB" (clear to auscultation bilaterally) and "WNL" (within normal limits) are exam shorthand that often arrives by template. Our guide to medical abbreviations for legal professionals covers how to read them without guessing.

SOAP puts the conclusion at the bottom. In a long EHR note with imported labs and templated exams, that means scrolling past pages of data to find out what the author thought. APSO moves Assessment and Plan to the top and leaves S and O below as supporting data.

In June 2013 the Association of Medical Directors of Information Systems published guiding principles for electronic documentation that included notes with Assessment and Plan at the top. The same year, Lin and colleagues reported in JAMA Internal Medicine that 83% of outpatient clinicians surveyed found APSO faster to write than SOAP and 81% found it easier to find data in.

The largest adoption study came from UCHealth in Colorado, which moved to APSO across 1 academic hospital, 4 community hospitals and more than 100 clinics. Sieja and colleagues reviewed 894 outpatient and 1,057 inpatient notes in 2014:

Nurses often use other structures for narrative notes. The 3 you will see most:

Many hospitals pair narrative nursing notes with flowsheets and chart only exceptions in the note. Our guide to charting by exception covers how to read that pairing.

No federal rule requires the letters S, O, A and P. The rules say what the record must show, and progress notes are how clinicians show it. For a hospital that takes Medicare, the medical records Condition of Participation sets the purpose of the whole record:

"The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services."

The same section requires every entry to be "legible, complete, dated, timed, and authenticated" by the person responsible, lists the results of all consultative evaluations and the documentation of complications and unfavorable drug reactions among the required contents, and requires the record to be completed within 30 days after discharge. Hospitals keep records for at least 5 years (482.24(b)(1)); many states require longer.

What billing rules say about the note

The CMS booklet on evaluation and management services, updated May 2026, sets the current Medicare approach. Since January 1, 2023, for most E/M visit families, the visit level is chosen by the level of medical decision making or by the total time spent. The history and exam must be "medically appropriate" and must meet the code descriptors, but they do not affect the level. When time is used, the note should record start and stop times or the total time. The booklet also defines the chief complaint as a short statement of the reason for the encounter, "usually stated in the patient's own words."

That change matters for reading notes written before and after 2023. A long templated exam in a 2019 note may have been there partly to support the billing level. In a 2024 note it adds nothing to the level, and a reviewer can weigh it as documentation of what was examined, not as billing padding. Our guide to getting medical records for a lawsuit covers requesting the billing records that sit beside the notes.

Open notes

The 21st Century Cures Act information blocking rules took effect on April 5, 2021. Until October 5, 2022 they covered the data elements in USCDI; since October 6, 2022 they cover all electronic health information. USCDI version 1 lists 8 clinical note types: consultation note, discharge summary note, history and physical, procedure note, progress note, imaging narrative, laboratory report narrative and pathology report narrative. Psychotherapy notes kept separately by a mental health professional are excluded.

Patients now read progress notes, sometimes before the next visit. That has changed how some clinicians write the Subjective and Assessment sections, and it gives a reviewer another source: portal messages in which a patient disputes what a note says.

An EHR lets a clinician start today's note from yesterday's, pull in labs and vital signs automatically, and insert a normal exam with a phrase. All 3 save time. All 3 can put text in a note that does not describe that day.

The best-known measurement comes from the University of California San Francisco, where Wang, Khanna and Najafi analyzed the source of every character in inpatient progress notes on a general medicine service from January to August 2016:

Payers noticed early. In 2014 the HHS Office of Inspector General reported that not all Medicare contractors could tell whether a provider had copied language or overdocumented in a medical record, and recommended that CMS give contractors guidance on EHR fraud risks and direct them to use providers' audit logs. The audit log is the record of who created, viewed and changed each note, and when. It is a separate system from the note itself. Our guide on EHR audit trails in malpractice cases covers how to ask for it.

What copied text looks like on paper

None of these proves poor care. Copied history is often accurate and a stable exam may be stable. But a frozen section is not evidence of a fresh assessment, and in a delayed-diagnosis case the day the note first changed is often the day the case turns on.

What each flag means

1. "Denies abdominal pain" on 06/11. The nursing notes chart pain of 7 at 06:00 and 10:00. The patient may have said something different to each person. The Subjective text is also identical to 06/10's, which suggests it was carried forward.
2. "POD 1" on post-op day 2. A stale day count is the clearest sign that a whole Assessment and Plan was copied. It does not prove the patient was not seen.
3. "Afebrile" with a temperature of 38.4. The fever was charted 3 hours before the note's time of service. Either the author did not look or the Objective text was not updated.
4. A missing white count. The value rose from 11.2 to 17.9 overnight and does not appear in the note. The question is whether the author saw it before signing.
5. A note signed 2 days late. Signed after the leak was found. A late signature is common and not wrong by itself, but the audit log can show whether the text changed between creation and signing.

The same 4 days on 1 timeline

The method below works for a 3-day stay or a 3-year course of outpatient visits. The order matters: know what the data showed before you read what the note concluded.

1. Collect every note type. Physician, advanced practice, resident, consult, nursing and therapy notes, with their addenda and attestations. Ask for notes in their final form and, if timing matters, the audit log.
2. List the notes by time of service. 1 line per note: date, time of service, time signed, author, credential, type.
3. Build the data timeline first. Vital signs, labs, imaging and medication times from their own records, not from the notes.
4. Read each note against the data from the 12 hours before it. Does the Objective section match? Does the Assessment mention the abnormal values?
5. Compare each note with the one before it. Mark sections that are identical, and any stale day count or resolved problem still listed.
6. Match every Plan item to an order and a result. A plan without an order, or an order without a plan, gets a line.
7. Check signature timing. Note any note signed after a key event: a transfer, a return to surgery, a death, a complaint.
8. Log each question with a page cite. So anyone can check it against the file.

Is this note evidence of what the clinician knew?

PROGRESS NOTE
Patient: [NAME / ID]    Date of service: [DATE]  Time: [TIME]
Author: [NAME, CREDENTIAL]    Service / setting: [UNIT OR CLINIC]
Hospital day / post-op day / visit number: [N]

S: SUBJECTIVE
Chief complaint (patient's words): "[ ]"
Interval history since last note: [ ]
Symptoms and review of systems: [ ]
Patient-reported medications, adherence, side effects: [ ]

O: OBJECTIVE
Vital signs (with times): T [ ] HR [ ] BP [ ] RR [ ] SpO2 [ ] on [ ]
Intake / output: [ ]
Exam by system: [ ]
Labs (with collection times): [ ]
Imaging and other results: [ ]

A: ASSESSMENT (1 line per problem)
1. [Problem]: [better / worse / unchanged], because [data]
2. [Problem]: [ ]

P: PLAN (1 block per problem, matching A)
1. [Tests, medications, consults, education, follow-up]
2. [ ]
Disposition / next review: [ ]

Time of service or total time (if billing by time): [ ]
Signature: [NAME, CREDENTIAL]  Signed: [DATE, TIME]

PROGRESS NOTE REVIEW LOG
Patient: [ID]    Facility: [NAME]    Dates: [FROM] to [TO]

Date | Time of service | Time signed | Author, credential | Page
     | Same as prior note? (S / O / A / P, or none)
     | Objective vs flowsheet and labs (match / mismatch + page)
     | Abnormal values not addressed in Assessment
     | Plan items without an order or result
     | Signed after a key event? (event, time)
     | Question

Example:
06/12 | 07:30 | 06/14 11:02 | Dr. E, MD | p. 207
      | S same as 06/11
      | "Afebrile" vs T 38.4 at 04:00 (p. 155)
      | WBC 17.9 at 05:10 (p. 183) not mentioned
      | None
      | Yes: signed after CT and return to OR
      | Was the WBC available at 07:30? Request audit log

Before you rely on a set of progress notes

• Every note type is presentPhysician, resident, advanced practice, consult, nursing and therapy notes.
• Addenda and attestations are attachedWith their own dates, times and signatures.
• Time of service and time signed are both visibleSome printouts show only 1. Ask for both.
• Flowsheet and lab times are in handTo test the Objective section against the source.
• Identical sections are markedDay by day, before you quote any of them.
• Audit log requested where timing is disputedCreation, edit and signing times for the notes that matter.

0 of 6 checked.

If a note looks changed after the fact, the method shifts. Our guide to altered medical records covers late entries and edits, and the medication administration record guide covers checking a Plan against what was given.

AI now sits on both sides of the progress note. It writes some of them, and it reads others.

Ambient AI scribes write the note

An ambient AI scribe listens to the visit through a phone or room microphone and drafts the note for the clinician to edit and sign. The largest published rollout came from The Permanente Medical Group, which enabled the tool for 10,000 physicians and staff in October 2023. Tierney and colleagues reported the first 10 weeks in NEJM Catalyst:

For a reviewer this changes 2 things. First, the Subjective section in a note written with a scribe may be a summary of a recorded conversation, edited by the clinician, rather than the clinician's own shorthand. Second, if the audio is not kept, nothing else captures what was said. Ask the facility whether an AI scribe was used for the visits in question, what its policy says about review before signing, and what, if anything, it retains.

Where AI helps a reviewer

The review in chapter 7 is mostly comparison: this note against yesterday's, this Objective section against the flowsheet, this Plan against the orders. On a long stay that means hundreds of notes. AI medical record review does the comparing well. A grounded system can pull every note into a dated list, place it on a timeline with the vitals, labs and nursing entries, and give every line a page-level citation back to the source, which turns a stack of notes into an AI medical chronology you can check.

It has limits. A large language model (LLM) asked to summarize notes without citations can produce a fluent sentence that is not in the record; hallucination is the reason every line needs to point to its page. Scanned notes need OCR, and handwritten entries on older paper charts are harder for any model. A summary can also repeat copied text as if it were a fresh finding, which is why the reviewer, the human in the loop, reads the flagged days in the source.

Medrecords AI works this way on the files you upload. It builds a cited medical chronology with each dated note as its own entry linked to its page, so you can read day 2 and day 3 side by side. It routes each page through OCR matched to its content, including handwritten entries. It answers questions like "every note that mentions abdominal pain, with the nursing pain score nearest to it" through cited Q&A and record search, and it flags records that should exist but were not produced. Flags are signals, not verdicts. It does not decide whether a note was copied or whether care met the standard, and it does not retrieve records from providers. It runs under SOC 2 and HIPAA with a signed business associate agreement (see security and HIPAA). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license.

If you are comparing tools, our guide to medical record review covers what to ask any medical chronology software vendor. See how note review fits medical malpractice, hospital nursing negligence and legal nurse consultant work.

What does SOAP stand for?

Subjective, Objective, Assessment and Plan. Subjective is what the patient reports, Objective is what the clinician measures and observes, Assessment is the diagnosis or impression, and Plan is what happens next.

Is a progress note the same as a SOAP note?

Not quite. A progress note is the type of document that records the patient's course. SOAP is the most common way to structure it. Some progress notes use APSO, DAR or free narrative instead.

Who invented the SOAP note?

It grew out of the problem-oriented medical record that Lawrence Weed described in the New England Journal of Medicine in 1968, which organized each note by problem with data, interpretation and plan.

What is an APSO note?

The same 4 sections with Assessment and Plan first. Health systems adopted it so readers see the clinician's conclusions without scrolling past imported data. At UCHealth, 84.5% of outpatient notes reviewed used it after the rollout.

What goes in the Objective section?

Measurable findings: vital signs, the physical exam, intake and output, lab results, imaging and other test results. In EHR notes much of it is imported, so check each value's time against its source record.

How do you write a good Assessment?

1 line per problem, naming the diagnosis and whether it is better, worse or unchanged, with the data that supports that trend. An assessment that ignores an abnormal value in the Objective section is the most common gap reviewers find.

Can patients read their progress notes?

Yes. Since April 5, 2021, federal information blocking rules require providers to give patients access to their electronic health information, and progress notes are 1 of the 8 note types in USCDI version 1. Psychotherapy notes kept separately are excluded.

How can you tell if a progress note was copied forward?

Compare it with the previous day's note section by section. Identical text, a stale hospital or post-op day count, and problems listed after they resolved are signs. The EHR audit log shows when text was created and edited.

Can AI write SOAP notes?

Ambient AI scribes draft notes from the visit conversation for the clinician to edit and sign. 1 medical group reported 3,442 physicians using one in its first 10 weeks. The signing clinician remains responsible for what the note says.

Can AI review progress notes for a legal case?

It can line up every note against vital signs, labs and nursing entries and cite each line to its page. Whether a mismatch means the care fell short is a judgment a qualified person makes after reading the source.

Is it HIPAA compliant to upload progress notes to an AI tool?

It can be, with a vendor that signs a business associate agreement, holds a SOC 2 report and commits in writing not to train on your data. A consumer chatbot without a BAA is a different matter.

Regulations and CMS guidance were read in full text from primary sources in September 2026, and quoted text is verbatim. Study figures come from the published papers. The mock note, patient, clinicians, times and pages in chapters 2, 6 and 7 are hypothetical. Product facts come from this site's product pages. Nothing here is legal or medical advice.

• Weed LL, "Medical records that guide and teach", New England Journal of Medicine 278(11):593-600 and 278(12):652-657, 1968: the problem-oriented medical record.
• 42 CFR 482.24(b)(1), (c), (c)(1), (c)(4)(iii), (iv) and (viii): retention, record content, entry standards, consults and complications, completion within 30 days.
• CMS MLN006764, Evaluation and Management Services (May 2026): visit level by MDM or total time since January 1, 2023; history and exam medically appropriate but not used for level; time documentation; chief complaint.
• Sieja A, Pell J, Markley K, et al., "Successful implementation of APSO notes across a major health system", American Journal of Accountable Care 5(1), 2017: note format shares, survey of 564 of 3,170 clinicians, AMDIS 2013 and Lin 2013 findings.
• Wang MD, Khanna R, Najafi N, "Characterizing the source of text in electronic health record progress notes", JAMA Internal Medicine 177(8):1212-1213, 2017: 23,630 notes, 18% typed, 46% copied, 36% imported.
• HHS OIG, OEI-01-11-00571 (January 7, 2014): contractors and copied or overdocumented records; recommendation to use audit logs.
• ONC, information blocking and USCDI: applicability dates and the 8 clinical note types in version 1.
• Tierney AA, Gayre G, Hoberman B, et al., "Ambient artificial intelligence scribes to alleviate the burden of clinical documentation", NEJM Catalyst, February 21, 2024: rollout figures and audio retention.