A SOAP note is a commonly used standard for documenting medical visits. SOAP notes give a consistent framework for summarizing clinical encounters and also provide a cognitive guide doctors can follow when conducting assessments. They are a systematic way to capture and store important medical information about a patient’s health.
SOAP notes are used across a wide range of human and animal medicine disciplines. Doctors and therapists in hospitals, urgent care clinics, specialty clinics, and private practices all use SOAP notes to summarize clinical encounters. While SOAP notes, specifically, aren’t legally mandated in every clinical setting, they do fulfill documentation requirements for care providers in the United States.
There are numerous benefits to keeping thorough SOAP notes. First, they ensure continuity of care for patients. Doctors can review previous SOAP notes and use that information when conducting follow-up appointments. SOAP notes are also useful for other providers who take on care responsibility for a patient. They facilitate smooth handoffs between various clinical settings and specialties.
SOAP Note Section Overview
The SOAP abbreviation stands for Subjective, Objective, Assessment, and Plan.
To demonstrate how a veterinarian might fill in each of these sections, let’s use the example of a Labrador coming in with gastrointestinal distress.
The Subjective Section of the SOAP Note
The Subjective section is where doctors capture the “narrative” surrounding a patient visit. It’s the space where care providers describe their perception of a patient’s health and general condition based on their own observations and responses to questions given by the patients themselves or patient caregivers (i.e., pet owners in veterinary medicine). This section should answer the question – “how does your patient look today?” (alert, lethargic, energetic, etc.) – and attempt to make a comparison to yesterday, if possible.
It’s common for the Subjective section to also include information like the patient’s past medical, family, and social history. It’s also where doctors summarize how patients describe their current medical issue, symptoms, and longevity.
In our veterinary SOAP note example, the Subjective assessment could contain the following information:
The patient is a 2-year-old spayed female Labrador who presents with diarrhea and vomiting. The onset of the patient’s symptoms started the same day as the appointment. Despite these symptoms, the owner confirmed that the patient was eating normally prior to the onset. There was no mention of any dietary indiscretions, exposure to toxins, or changes in diet that could have contributed to her symptoms. The owner did not report any other signs of illness or changes in behavior.
The Objective Section of the SOAP Note
The Objective section is for keeping specific data points, like vital signs, lab results, and other diagnostic information. The Objective section enhances the narrative nature of the Subjective section with tangible evidence. It only includes findings, not an assessment.
Doctors have different ways of organizing the information contained in the Objective section. A common framework includes the following:
1st line – T, P, R, BCS, body weight, mucous membranes, CRT, hydration status
Eyes, ears, nose, throat (EENT)
Peripheral lymph nodes (PLNS)
Heart + lungs (H/L)
Abdomen, rectal exam findings (ABD)
Urogenital, rectal exam – prostate or urethral palpation per rectum (UG)
Musculoskeletal (MSI)
Integument
General neurologic exam of mentation, gait, and cranial nerves (N)
Depending on the specific complaint presented by the patient or caregiver, some sections may be more thorough than others. For example, it may make sense to write a full NEURO or include additional ORTHO details under the MSI section given a complaint of lameness.
The Objective section will also capture any subsequent lab results, imaging results, or diagnostic testing as a result of a hospitalization after initial exam findings. With these data points, common practice is to only include abnormal and relevant normal values.
In our SOAP note example, the Objective assessment might include:
Constitutional: alert, no acute distress, bright, well-nourished.
Ear, eyes, nose, throat: pink gums, clear eyes, pink tongue, normal dentition.
Peripheral lymph nodes: no palpable lymph node swelling.
Heart Lungs: clear lungs on auscultation, normal sinus rhythm, pulses strong and synchronous.
Abdominal: soft, non-painful, no palpable organomegaly, masses, or other abnormalities.
Genitourinary: grossly normal genitourinary exam.
Musculoskeletal: normal extremities, good muscle tone.
Integumentary: no abnormal findings.
Neurological: normal gait and mentation, grossly normal activity.
The Assessment Section of the SOAP Note
The Assessment section describes what the doctor thinks is happening with the patient based on the Subjective and Objective findings. In cases where Subjective and Objective accounts diverge, it’s up to the doctor to determine the right path forward.
A helpful framework for approaching the Assessment section is to list out each problem with relevant rule-outs. Problems are derived from historical findings, physical exams, and lab results. Ideally, individual lab abnormalities should have differentials.
In our example, the Assessment section could contain the following:
Vomiting/Diarrhea - r/o: primary GI (dietary indiscretion/gastroenteritis, parasites etc) vs secondary metabolic (pancreatitis, Addison’s etc)
The Plan Section of the SOAP Note
The Plan section is where clinicians describe the treatment approach to address the patient’s condition. This may include referrals to other specialties, additional lab tests, or medical prescriptions. Doctors can create separate plans for each problem listed in the Assessment section. It’s also common for veterinarians to simply describe what they want to do and why, as some testing and treatments may address multiple problems at once. This helps remove some repetitive documentation.
Plans for hospitalized patients should include thorough details. For instance, doctors should list specific doses, routes, frequencies, and rationale for drug prescriptions. Types, rates, and rationale should also be included for fluids.
In our example, the Plan section might include the steps below:
Completed:
3.2 ml Cerenia subcutaneously
0.5 ml vitamin b12 subcutaneously
300 cc fluids subcutaneously
Discussed:
Patient's condition to be closely monitored, with further diagnostics like blood work and radiographs planned if no improvement by the following day.
Inpatient SOAP Notes
Compared to outpatient SOAP notes, inpatient SOAP notes should be dynamic. It’s best practice for doctors to update inpatient SOAP notes with what has changed day to day. This approach ensures a more robust log of patient progress and enables veterinarians to understand their cases more deeply.
The SOAP Note Burnout Problem for Veterinarians
Burnout is a serious problem in veterinary medicine. A typical day in the life of a general practice veterinarian helps illuminate why.
When a doctor first gets to work, they may have a stack of labs to interpret and plans to develop for each depending on the results. They will then have to contact every pet owner to discuss the appropriate next steps. This may or may not happen immediately depending on the day’s scheduled appointments.
For each scheduled appointment, veterinarians meet face-to-face with pet owners and pets, assessing the animal’s condition and developing treatment plans, if necessary. In between these visits, the doctor may have to handle drop-off appointments - pets with urgent needs that weren’t able to schedule appointments in advance.
All of these interactions, scheduled and unscheduled, have to be documented either as a client communication or a medical record, i.e., SOAP note. It’s not uncommon to spend 1-2 hours or more on just the medical record side of things. Although necessary, this work is duplicative in nature. Veterinarians experience every interaction twice, once in real time with patients and then a second time when completing the related documentation.
Some veterinarians will write SOAP notes directly after a visit if they have time. Others will wait until the end of the day or even the end of the week to catch up on all previous appointments. Of course, this approach compromises the quality of the SOAP note, as it’s difficult for veterinarians to remember all the important details of a visit.
Compounding the issue is the fact that veterinarians are generally salaried or paid by shift - not by the hour. So, none of this after-hours paperwork is compensated. Today’s graduates are also being taught at a standard closer to what is seen in human medicine. This has positive implications for medical care quality, but is difficult for veterinarians to sustain, as they don’t have access to the same tools or support. What’s more, many veterinarians aren’t just tired – they’re desperate. Studies have confirmed that veterinarians are at an increased risk of suicide and stress, compared to the general population.
Fortunately, veterinary medicine is finally catching up to human medicine on several fronts. With the power of AI, it’s now possible to automate SOAP note writing and free veterinarians of this repetitive and time-consuming responsibility.
How PupPilot Handles SOAP Notes
PupPilot generates fully formatted SOAP notes based on audio recordings of clinical visits. Veterinarians only have to open up our mobile or web app, hit record, and then conduct their appointment as normal. When the visit is over, they submit the audio recording, wait two minutes, and then review the SOAP note that PupPilot generates. We create both a short and long version of a SOAP note, giving doctors a choice on what version they want to use. Veterinarians can also make edits and then copy and paste the note directly into their patient management system. With PupPilot, veterinarians and vet nurses essentially eliminate the duplicative follow-up work that quickly becomes overwhelming at busy clinics. In addition to drafting SOAP notes, PupPilot also generates client handouts, visit summaries, and callback notes to make client education and follow-ups even easier.
The SOAP notes we produce are optimized for accuracy, completeness, and relevancy. We know these qualities are essential, because our leadership team is acutely aware of the SOAP note burden. Our cofounder, Dr. Nora Peters (DVM), recently transitioned from a career as a veterinarian to a software engineer, but not before spending countless late nights meticulously crafting her SOAP notes. Her husband, Gary, is a 2x startup founder with AI engineering expertise who is now applying his AI knowledge to veterinary medicine.
To put PupPilot to the test in your clinic, schedule a demo with Gary and share more details about your practice. We’ll get you set up in the mobile and web applications and walk through best practices. Shortly after, you’ll be able to start generating SOAP notes for your visits.
Get started here.