What Are the Advantages of Using SOAP Notes in Healthcare Documentation?

Documenting the details of every patient interaction is a critical aspect of healthcare. But without structure, medical notes can become unwieldy and difficult to interpret. SOAP notes are a method that improves organization and accuracy. It’s a system that compares patient experience with objective clinical findings to create actionable treatment plans. Understanding the benefits and advantages of using SOAP notes in healthcare documentation can help medical practitioners integrate them more effectively into their processes. 

Components of a SOAP Note

SOAP stands for Subjective, Objective, Assessment, and Plan. This format has been used in healthcare settings since the 1950s and reminds practitioners what to focus on during patient interactions. Here’s a brief overview:

• Subjective: The patient’s claim, including their experience of the injury, illness, pain, or other condition. The attending professional can gather a history of present illness (HPI), noting when the problem began and other relevant data. 

• Objective: The unbiased observations of the assessing physician, therapist, or nurse, which may include vital statistics, lab results, and other factual data.

• Assessment: The current diagnosis based on the data from the previous two sections. 

• Plan: The next steps based on the data in the assessment. 

While this format is structured, it’s also flexible and usable in a range of disciplines. 

Key Advantages of Using SOAP Notes

So, what is the benefit of using SOAP notes? Primarily, the SOAP format provides a structure that encourages concise yet complete notes that focus on the critical aspects of patient care. Here are just a few key benefits of using SOAP notes. 

Better Communication and Collaboration

In many cases, patients see multiple medical professionals. Concise, accurate notes allow healthcare personnel to quickly understand the patient’s condition. For example, someone who works in physical therapy will know from SOAP notes that a patient is hypermobile and needs adjusted exercises. 

Efficiency and Consistency

The ability to quickly review notes enables treatment plans to move along more efficiently. There’s no need to contact the previous physician or wait for more information. Similarly, insurance claims are more likely to be resolved efficiently when relevant data is readily available.

Reduced Risk of Physician Burnout

Writing excessive notes is an administrative burden on overworked healthcare personnel. The American Medical Association (AMA) notes that while physician burnout rates dropped to a new low of 45% in 2024, this figure is still high. One of the key drivers is administrative tasks. SOAP notes help reduce healthcare administration, particularly when physicians can quickly upload notes directly into electronic systems. 

Better Patient Outcomes

When healthcare professionals are fully informed and less stressed, they perform better for their patients. More concise, accurate notes can also trim treatment timelines, helping patients get the procedures or medication they need faster. 

Practical Examples of Advantages of SOAP Notes

SOAP notes work in multiple disciplines. While they’re essential for urgent care triage, they’re also applicable in long-term care and chronic conditions. Let’s take a look at a few examples of SOAP notes in action.

SOAP Notes Examples: Nursing 

SOAP notes for nurses encompass a wide range of patient interactions, from injuries treated in the ER to requests for pain medication from hospitalized patients. Nursing SOAP notes may look like this:

• S: Patient reported extreme head pain; felt overheated and wanted medication.

• O: Patient’s vitals were normal; no fever or other physical symptoms. Previous notes confirmed that pain medication was due in the next half-hour as per schedule.

• A: Talked to the patient through the medication schedule and explained the consequences of overdose. Administered water and food to the patient and scheduled a checkup for 20:00 hours.

• P: Ensure pain meds are given at the correct time; recheck vitals to confirm no fever or other problematic symptoms. 

SOAP Notes Examples: Speech Therapy

Speech therapists need to differentiate between patient experience and fact. A patient with speech difficulties may suffer negative feelings that make their condition seem worse. A therapist can use SOAP notes to document and compare the patient’s experience and the actual challenges:

• S: Patient reports slurring words and stuttering since a head injury; they state that it’s taking over social interactions and leading to isolation.

• O: Assessed using standardized speech tests. Stuttering was present on [X] number of sounds, but slurring was minimal. 

• A: Symptoms suggest mild, non-progressive dysarthria.

• P: Set up a series of speech and tongue exercises to increase control and improve patient confidence. Suggested group CBT sessions to improve self-esteem.

Note structures like these can benefit practitioners in chronic pain management, psychological therapies, and many more disciplines. The format is almost universally transferable, understood across different disciplines, and improves collaboration. 

Tips to Maximize the Benefits of SOAP Notes

The more effective the notes are, the better they benefit both patients and physicians. Knowing how to craft excellent SOAP notes helps maximize their benefits. Follow these tips for success. 

Carefully Separate Subjective and Objective

Avoid placing assumptions in the “Objective” section. In the speech therapy example, if the patient says, "I can never pronounce the 'R' sound," that's "Subjective" and belongs in the “S" section. However, a speech therapist could test this and note, “Patient pronounces 'R' sounds perfectly only 15% of the time,” in the “O” section. The objective assessments help support or refute assumptions in the subjective claims.

Keep Language Accurate but Simple

Notes may be viewed by medical practitioners, from students to consultants. Use the most straightforward language possible without losing the essence of what you’re communicating. Try reading notes out loud to see if they’re easy to follow. 

Be Specific

Vague notes can lead to incorrect physician assumptions. A note stating that a patient is “managing pain well” may lead to the next doctor removing pain medication from the patient’s prescription. Instead, the assessing physician could note, “With [X] mg of the new pain medication, the patient finds that they can complete most daily tasks without discomfort.”

Ensure Notes Are Integrated Into Electronic Health Record (EHR) Systems

Reams of paper notes or notes logged on disparate systems create data silos and inaccuracies. Work with expert consultants to understand the capabilities of your EHR system and how to easily integrate notes. Properly stored and documented SOAP notes are quickly available to the next physician and, in some cases, to the patient. 

Conclusion: Why is Using SOAP Notes So Advantageous in Healthcare Documentation?

Practical SOAP notes help create a consistent approach to patient interaction. Patients know what to expect, but more importantly, they trust that correct information will support ongoing, effective treatment plans. Physicians can manage their workloads better and, when receiving notes from other medical professionals, quickly understand the patient's needs and act accordingly. 

If you need support with your EHR system to ensure you can store and transfer notes securely and safely, talk to TempDev. We provide a range of consultation services for healthcare organizations using NextGen technologies. We can help you integrate SOAP notes, redesign workflows, and utilize effective templates to streamline your processes even further. Contact us online or call 888.TEMP.DEV.