Making Sense of the Soap Note in the Digital Ear: A Primer for Audiologists

Author: Alicia D.D. Spoor, Au.D.

Ugh! The dreaded SOAP (Subjective, Objective, Action/Assessment, Plan) note. For many students, it’s one of the least favorite things to learn about when you're in professional school, and it's likely one of the least exciting topics to read about. Yet documentation is one of the most crucial things that needs to be done after providing services to a patient – even in the digital age of Suri and Skype. Let’s begin our odyssey into SOAP notes by discussing the concept of a medical record. A medical record is the systemic documentation of a person’s medical history and care. It can be a handwritten record or a record that exists in the cloud. Either way, it is a summation of all of the documents related to a patient. No matter where the record is stored, a provider must follow proper guidelines when creating it. Good documentation protects patients, as well as providers, and provides quality assurance by having a complete set of information in a standardized format. The objective of this primer is to review the essential details of accurate medical record keeping using the SOAP note as a tool.

If patients could tell a provider every detail, about every appointment they have ever had, every procedure (laboratory work, diagnostic testing, body scan, blood work, treatment, etc.) that’s ever been done to them, it would be part of the medical record. As we all know, however, even the most astute patients are not likely to remember every detail of each appointment they have had with a provider, and in turn convey this information accurately to another provider at their next several appointments. Because people do not have airtight, photographic memories, we have documented medical records. It's worth noting that, just because medical records are documented, does not mean that they do not also contain inaccuracies. They do. Oftentimes, this is because providers fail to write detailed and effective SOAP notes.

Writing effective SOAP notes starts with the provider’s ability to collect accurate and thorough information about patients before they are seen for an evaluation. This includes demographic information, such as: name, address, date of birth, contact information, emergency information contact, and a medical record number, if applicable. It would also include every piece of information related to a third-party payer or insurance information. This includes:
  • front and back copies of the insurance card
  • physician information, especially referrals, if needed
  • proof of identification (e.g. a government-issued photo ID, driver’s license, passport, etc.)
  • notice of privacy practices for each office a patient has visited
  • power of attorney, if applicable
  • health care proxy, if applicable
  • permission to treat a patient if s/he is under 18 or 21 years old (i.e. the legal age of an adult, according to state definition) and is unaccompanied by a parent and/or caregiver
  • consent to treat
  • consent or any other type of authorizations
  • consent to interact and bill a third-party payer and/or insurance company
  • release of information, if needed
  • advanced beneficiary notice (ABN) information, if needed
  • insurance waiver for commercial insurance plans, if needed.
The medical record should also include a full list of coding, billing, and reimbursement documents. This would include documentation, such as the patient encounter form/superbill from each practice and every single office visit, regardless if a payment was made by the patient or a third party (insurance) provider. It would also include documentation sent to referring and primary care physicians after each visit, correspondence to and from other providers, emergency contacts, patients, parents/guardians/caregivers, spouses, adult children, and the patient themselves. The medical record should contain all contacts and attempted contacts made with other providers, including phone calls, email, faxes and it would include reports from other providers prior or during a patient’s treatment. In short, any encounter with a patient, either in person, electronically or over the phone must be documented in the patient’s medical record.
History of Soap Notes
The concept of SOAP notes is usually credited to Dr. Lawrence Weed. Prior to Weed’s recommendations (in the 1960's), medical records were loosely structured, making the task of finding information tedious and time consuming. Prior to office computers being standard, medical records were hand written and there were very few, if any, guidelines to follow for organizing a medical record. In the 1950s, Weed began developing an idea for a change in the medical records; he initially proposed a problem-oriented medical record (POMR). Weed further explained that SOAP notes would contain a detailed case history, allergies, surgeries, hospitalizations, medications, noise exposure, prenatal information, postnatal information, family history of hearing loss onset, and balance information and onset.
Soap Notes
The purpose of a SOAP note is to improve the quality and continuity of services by enhancing communication among professionals. Any details related to a patient’s visit should be documented in the appropriate section of the SOAP note. A well written SOAP note will ensure that the original treating provider can recall details about the patient and new providers will have appropriate background information prior to seeing the patient. In the profession of audiology, patients typically see the same provider for continuity of care over many years and a strong relationship is developed. Due to this long-standing relationship, audiologists must ensure that the SOAP notes are not weakened due to the level of comfort with a patient. The SOAP note also allows providers to document objective results from a patient encounter in an organized, standardized manner. A well written SOAP note provides accountability for the provider and patient, corroborates the delivery of appropriate care, and supports clinical decisions made by the provider. SOAP notes also helps ensure patient safety by reducing medical errors through consistent, appropriate documentation and logical decision making. Additionally, the SOAP note becomes a primary communication tool between providers, administrators, government agencies, and third-party payers.

After learning how to document medical records using a SOAP note format, the act of completing the note becomes very convenient and, with the help of automated templates, can ensure that no pertinent information is missing. After mastering SOAP notes and having a few years of experience in the profession, an experienced audiologist can more easily report on the patient’s case history and tailor a report to referring physicians. However, until a provider is comfortable with every detail, a SOAP note can guide the mental thought process and decision making to ensure that Best Practices are met. SOAP notes also provide justification as to why a procedure was not completed during a patient visit. Remember that every attempted or actual patient encounter must be documented by the provider, patient coordinator, billing specialist, hearing aid dispensers, and any other member of the office staff. Patient encounters that do not include the patient, but which still must be documented, include communication with referring physicians, other providers, third party payers, government agencies, worker’s compensation cases, attorneys, etc. Learning to use SOAP notes helps develop critical thinking skills and ensures logical structure for an appointment and during the documentation process.

If you’re a student just learning the notetaking process, or an experienced provider who needs a refresher course on SOAP notes, here are the details of this familiar acronym.
S is for Subjective
In the SOAP note acronym, S stands for Subjective. The subjective portion of the note is where patient data is gathered. Typically, the subjective portion of the SOAP note is often the hardest section to write, as subjective information needs to be removed from objective information. Although it is important to be complete, this section should be as brief and concise as possible. One way to keep the subjective SOAP note concise is to ask the patient direct questions during the interview/case history process. The patient’s perception of the problem/reason for the appointment/chief complaint should be easily identifiable in the Subjective section to an outside reader. When noting the reason for the appointment, the provider can summarize the patient’s information, unless the patient uses an unusual phrase or description (e.g. “my tinnitus sounds like a wheezing noise”). If the need to quote the patient does arise, keep the quote brief.

The content in the Subjective part belongs to the patient unless otherwise noted. If the subjective information is being provided by someone other than the patient, it needs to be clearly noted at the beginning of the note. For audiologists, the Subjective part of a SOAP note is typically the case history, taken from written materials, questionnaires, and interviews. The chief complaint/reason for the current appointment, along with the referring physician, should be stated first in the Subjective portion of the SOAP note. This will also guide the audiologist and reader towards the diagnosis (Assessment part of the SOAP note).

In addition to documenting the referring physician, medical necessity needs to be clearly stated. Medical necessity is not the physician’s order; rather, it is the one or more things that the patient reports which would lead a provider to complete services for the purpose of evaluating, diagnosing, or treating a condition. For example, medical necessity might be having a physician’s written order and the patient stating that his tinnitus has worsened since his appointment two months ago. This portion of the SOAP note should include a review of symptoms with appropriate documentation when there is no history of a disease. When documenting dates of service, the provider should use dates relative to the appointment date (e.g. “three days ago”), not absolute dates (e.g. “June 4, 2011”). Dates used with medications should clearly document how many days the patient has taken the drug with the entire dosage of days. For example, a provider would document “Amoxicillin: day 4/14.” This implies a 14 day course of Amoxicillin, but the patient has only taken 4 days of the drug. Medications need to be listed in the subjective SOAP note at every appointment.

The provider should encourage patients to bring a copy of their current medication list to the appointment, or request a current medication list be sent by the primary care physician to the treating provider. The treating provider needs to review each medication with the patient to ensure the list is accurate. Any changes need to be documented and the primary care physician and the provider who prescribed the medication initially should be notified of the change. If a copy is made of the patient’s medication list, the copy needs to be marked with the word “Copy,” the date it was reviewed, and the signature and credentials of the provider who reviewed it. Providers also need to ensure that the copied medication list has the patient’s name, date of birth, and any other identification number, if applicable. The copy should be placed or scanned into the patient’s file and the SOAP Note statement should read: “Copied and reviewed patient’s current medication list, dated Month, Date, Year.” Documentation of current medications is not only best practices, but is required for every visit by every provider to meet Physician Quality Reporting System (PQRS) measures, which directly relate to reimbursement rates (via disincentives). If there are no changes in the patient’s current medication list, it can be documented as: “Reviewed medication list (dated: month, date, year). Patient denied any changes in current medications.” Best Practices state that a complete list of medications include the name of the medication, frequency it is taken, dosage, and route. Allergies and medication/prescription drug allergies should also be noted in the subjective section. Audiologists specifically need to ask about latex allergies so infection control procedures using latex gloves can be addressed. If there are no allergies, the acronym “NKA (No Known Allergies)” is appropriate; if there are no known drug/prescription drug allergies, the acronym “NKDA (No Known Drug Allergies)” is appropriate.

Questionnaires provided to the patient before, or during the appointment, also need to be included in the subjective section of the SOAP Note. The provider should review the data provided, sign, and date the questionnaire, indicating that it was reviewed. The questionnaire can then be scanned into the patient’s medical record and referenced in the SOAP Note. For example, the written documentation may read: “APHAB questionnaire (dated: month, date, year) was reviewed by the provider prior to the communication needs appointment.” Finally, any follow-up questions the provider asks in-person need to be documented within subjective SOAP note.
O is for Objective
The objective section of the SOAP note is factual, often observable, information. All the information will be quantifiable, via sight, sound, and measurement and will not include any information from the patient. Any written document from an outside source that is provided to the treating provider, will be documented in the objective section. Written materials should be treated the same as questionnaires: reviewed and referenced by the provider in the SOAP note and then scanned into the medical record. If a patient provides verbal information and a provider has written documentation on the same event, it should be listed in both the Subjective and Objective sections of the SOAP note. This duplicate information will help support any clinical findings from the appointment. When documenting objective information, a provider can use professional observation and judgement, if stated appropriately.

Results from the physical exam will be described in-detail in the Objective section. The length of the Objective section may be significant, depending on the amount of testing completed, the reason the tests were completed, will help make a case for the diagnosis (Assessment part of SOAP notes) and help determine a differential diagnoses, if necessary. Test data may also be supplemented with drawings, diagrams, charts, scoring sheets, audiograms, etc. These “artistic” supplements can be beneficial when describing cerumen and/or foreign objects in the ear canal, unique properties on the tympanic membrane, and in other situations. It is worth noting that an audiogram itself, is not complete documentation and does not replace a SOAP note. The provider needs to document equipment models, calibration dates, and testing methods, if the data is not noted on the audiogram, especially for worker’s compensation cases, potential legal cases, and for occupational testing. It is appropriate for the provider to state the reliability of the testing, based on his/her professional judgement. Although the test results may be normal, or within normal limits, documentation of the entire appointment needs to be thorough. A complete Objective section will ensure proper billing and coding reimbursement and also provide information for the diagnosis.
A is for Assessment
Assessment, sometimes termed diagnosis, depending on a state’s scope of practice, is the summary of the subjective and objective information and encompasses the provider’s critical thinking and clinical training. It should be a conclusion that is easily apparent after reading the findings from the objective section of the SOAP note. The Assessment section will be one or two sentences, at most, and highlight significant abnormalities. Some providers prefer to write full sentences in their Assessment, while others prefer numbers or bullets. This formatting preference should be consistent throughout the entire SOAP note. A well-written Assessment will easily identify diagnosis codes for billing and coding purposes. The Assessment section is typically what referring providers and primary care physicians will look at first. For example, when an audiologist receives an MRI report for a patient with asymmetrical hearing loss and positive acoustic decay, he will likely not read the Subjective section, as he has taken his own history, nor will he likely read the Objective section since the details of radiology may not be well known. However, an audiologist will typically flip to the Assessment (diagnosis) to determine whether there is a vestibular schwannoma.

Any unexplained complaints from the patient need to be reported, using professional language, in the Assessment section. Although this addition may make the section of the SOAP note a little longer, it can be important, especially for legal cases, worker’s compensation cases, and functional hearing loss cases. An example may be: “Unable to find an objective explanation for the patient’s feeling of ‘water in the ears.’”
P is for Plan
The final part of the SOAP note is the Plan, sometimes referred to as “Recommendations.” This section details the counseling, intervention, and follow-up for the patient. There are typically two parts to the Plan section: the action plan and the prognosis. The action plan details the interventions used when counseling the patient on the results of the testing. References to handouts and/or educational materials provided to the patient should be noted or included in the medical record. Written information can help reduce the liability of the provider and will also help with patient compliance during follow-up visits. Should the provider’s office have a notation for handouts, an appropriate documentation for this would be: “Provided tinnitus handout #3 to patient.” This simple statement implies that the patient received the handout, an explanation was provided, the patient was given instructions to follow, and the patient was encouraged and given the opportunity to ask questions about the instructions and content. The very last recommendation should be the patient’s next appointment with that treating provider. If no immediate follow-up appointment is recommended, it is appropriate to document “return as needed” or “return if [specific] problem worsens/returns.” Should no specified date be given for the patient’s return, it is implied that the provider is allowing the patient to make the clinical judgement if, and when, to return. Treatment plans will be included in the Plan section of the SOAP Note. If differential diagnoses were made in the Assessment section, each diagnosis needs a treatment plan.

The Plan section can be in sentence form or in a numbered format, depending on the style preference of the provider. However, it should be consistent with the Assessment and other portions of the SOAP note.

Based on the provider’s status and state-defined scope of practice, referrals may be an integral part of the Plan section. Any provider and/or organization specific referrals need to be completely documented in this section with the provider's full name, credentials, and agency/organization. If a provider is unable to appropriately, or legally refer a patient, documentation should be made to notify the referring provider and primary care physician of the recommendation. An example of this type of documentation is: “A recommendation was made for a gadolinium enhanced magnetic resonance imagining (MRI) test to rule out a retrocochlear site of lesion at the referring provider/primary care physician’s discretion.” Lack of referrals can cause significant patient safety problems and could be construed as unethical by professional organizations. Therefore, even if a provider cannot refer in his/her state, recommendations should be made “at the physician’s discretion” to continue the patient’s treatment. Appropriate referrals/recommendations may include additional procedures, repeat testing after a different time, location, date, under different circumstances, laboratory work, treatment options, consultations, etc. Should a patient need a recommendation for returning to work/school, a detailed description of the patient’s/student’s daily requirements need to be documented in writing and, as with any other provider report or handout, the treating provider will review, date, sign, reference it in the Objective Section (and perhaps again in the Plan section of the SOAP note) and scan it into the medical record. Educational clearance needs to be very detailed, for each educational environment, including a list of appropriate accommodations by staff members and restrictions for the student/patient. These types of recommendations are more likely to be provided by a medical doctor (M.D.), except in the cases of agencies/homes who care for people with developmental disabilities.
Making Sense of the SOAP Note
The number one rule for SOAP notes, for any provider is: “If it’s not documented, it didn’t happen.” The SOAP note should begin with the full date (month, day, year) and time of the patient’s appointment and the full date and time of the SOAP note dictation/writing. If a SOAP note is hand written, it needs to be legible, neat, and free of any spelling and/or grammatical errors. SOAP notes should be concise, materials should be clearly stated, and overall, there should be little professional jargon. Professional jargon is more acceptable in the Objective section, when test details may warrant the specific professional terminology and in the Assessment sentences. An easy-to-understand, accurate Assessment and Plan section is easy to read and easy to write when SOAP notes are mastered. The final page needs to contain a full, legal signature of the provider who administered treatment, with his/her title and date. A legal signature must include at least the first initial, full last name, and credentials. Some states may require the provider’s license number on some or all of the documentation. If this is the case, the signature may read: “J. Smith, Au.D., Doctor of Audiology TN#98245 04 May 2013.”

If you’re new to writing SOAP notes or want a quick refresher, Table 1 might be a handy reference. It outlines the essential components of SOAP notes and provides some simple examples.
Table 1. A summary of SOAP Definitions and Examples. From Hosford-Dunn, H., Roeser, R.J., & Valente, M. (2007). Audiology Practice Management (2nd ed.). Thieme. Used with permission.
A Summarization of SOAP Definitions and Examples
Section Definitions Examples
Subjective (S) What the client tells you
What pertinent others tell you about the client
Basically, how the client experiences the world
Client's feelings, concerns, plans, goals, and thoughts
Intensity of problems and impact on relationships
Pertinent comments by family, case managers, behavioral therapists, etc.
Client's orientation to time, place, and person
Client's verbalized changes toward helping
Objective (O) Factual: What the counselor personally observes/witnesses
Quantifiable: What was seen, counted, smelled, heard, or measured
Outside written materials received
The client's general appearance, affect, behavior
Nature of the helping relationship
Client's demonstrated strengths and weaknesses
Test results, materials from other agencies, etc., are to be noted and attached
Assessment (A) Summarizes the counselor's clinical thinking
A synthesis and analysis of the subjective and objective portion of the notes
For counselor: Include clinical diagnosis and clinical impressions (if any)
For care providers: How would you label the client's behavior and the reasons (if any) for this behavior?
Plan (P) Describes the parameters of treatment
Consists of action plan and prognosis
Action plan: Include interventions used, treatment progress, and direction. Counselors should include the date of next appointment
Prognosis: Include the anticipated gains from the interventions

Implementing SOAP Notes in a Clinical Setting
Immediately after a patient encounter ends, the provider needs to review his/her notes and start construction of the SOAP Note. This ensures that details from that patient’s appointment are fresh in the provider’s mind. Depending on the provider’s level of experience, a few minutes may be needed in-between appointments to collect thoughts, gather information, and write the SOAP Note.

If an office does not have an electronic medical records (EMR) software system, a provider can make use of templates and macros. Templates may be created by a provider or purchased from an organization or software company. Common phrases and acronyms used can be stored in commonly-used computer programs, including the Shorthand program or in the macro shortcut of Microsoft Word. Another alternative to the EMR software is dictation.

After a SOAP note is completed, it needs to be distributed to the appropriate providers. Reports should be sent within 1-2 business days after a patient’s appointment and prior to any days off the treating provider may have (e.g. weekend, vacation). Communication to other providers may include the entire SOAP note, a reduced report with pertinent information, a “thank you for the referral” card, and/or a copy of supporting handouts/documents (e.g. the audiogram). If the patient is a Medicare beneficiary, sending communication to the referring provider with documentation of the outcomes will meet the Medicare guidelines and medical necessity. Good reports can lead to a long-lasting professional partnership with other providers. It will also demonstrate a provider’s expertise, allow for open communication, and build trust.

A well written SOAP note requires appropriate education, practice, and experience. Once mastered, it creates open communication across treating physicians/providers and meets insurance requirements for medical necessity. Mastering the SOAP note format can come from practice in the professional school and internship/externship environments. Documenting the patient’s information in the Subjective section, the test results and outside reports in the Objective section, Diagnosing the patient’s complaints, including differential diagnoses and highlighting abnormal finds in the Assessment section, and providing treatment steps in the Plan section create a well-written SOAP note. Alternatives to SOAP notes can also be used efficiently by a provider and to ensure the same information is conveyed. The use of EMR software systems can aid a provider in the documentation process and help ensure patient safety, security, and quality controls are met. Providing the best patient care, utilizing Best-Practices, and ensuring patient safety are the end goals for all healthcare providers.    
Alicia D.D. Spoor, Au.D. is the Audiologist and President of Designer Audiology, LLC, located in Highland, MD. Previously, she was part of the cochlear implant and hearing aid teams at the Mayo Clinic Arizona. Dr. Spoor earned her Doctor of Audiology degree from Gallaudet University in Washington, D.C. and her Bachelor of Arts degree from Michigan State University in Audiology and Speech Sciences. While at Gallaudet University, Dr. Spoor taught at both the undergraduate and graduate levels. She is currently the President Elect for the Academy of Doctors of Audiology and Legislative Chair of the Maryland Academy of Audiology.
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