SOAP Note
Subjective, Objective, Assessment, and Plan — the four-part structured clinical note format used in most ambulatory encounters.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Documentation
- Primary sources
- 2
- Workspace handoff
- templates →
Where this comes up
Providers meet this term in the chart and at the post-visit review — encounter notes, problem lists, medication reconciliation, signed orders, and the time/elements that defend the billed code. If documentation does not support the code, the code does not survive an audit.
Full definition
What it is in practice
SOAP is a widely-taught format (originated by Larry Weed) that organizes a clinical encounter into the patient's reported history (S), measured findings (O), the clinician's interpretation (A), and the next-step plan (P). Many EHR note templates follow this structure.
How it shows up in your practice
E/M leveling depends on what is in the chart. Build SOAP templates that prompt for the data and risk elements that drive MDM. Avoid template auto-population that creates cloned documentation.
Sources
- CMS — E/M Services Guidehttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
- AMA — E/M Documentation Guidelineshttps://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
Use SOAP-aligned note templates from the Templates engine
Open templates →Related terms
- CodingMedical Decision Making (MDM)One of two methods (with time) for selecting an E/M level, based on the number and complexity of problems, the amount and complexity of data reviewed, and the risk of complications.
- DocumentationDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- DocumentationDocumentation CloningThe practice of copying prior or template-generated documentation into a new encounter note without updating it for the current visit.
- CodingE/M CodingEvaluation and Management codes (99202-99499) used to bill office, hospital, and other professional visits.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryDocumentation CloningThe practice of copying prior or template-generated documentation into a new encounter note without updating it for the current visit.
- GlossaryDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- GlossaryE/M CodingEvaluation and Management codes (99202-99499) used to bill office, hospital, and other professional visits.
- GlossaryMedical Decision Making (MDM)One of two methods (with time) for selecting an E/M level, based on the number and complexity of problems, the amount and complexity of data reviewed, and the risk of complications.
- GlossaryMedical Decision Making Risk ElementThe third axis of MDM-based E/M leveling, reflecting the risk of complications, morbidity, or mortality of patient management.
- RegulationMLN: 2021 E/M Office Visit Coding RevisionsReference to the 2021 CPT E/M office visit (99202-99215) code revisions: history and exam no longer used for code selection; medical decision making or time controls.
- Glossary99214 vs 99215The two most common established-patient office E/M levels; 99214 represents moderate complexity and 99215 high complexity.
- GlossaryCPT (Current Procedural Terminology)The AMA-maintained code set that describes medical, surgical, and diagnostic services for billing.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.