Article: If you’re not the first medical professional to see the patient, they may already have a SOAP note. Look for any changes in the patient’s concern, and be sure to list if there were positive or negative effects to prior treatment. For example, if you had previously prescribed an antibiotic, you may record how the affected area has less swelling. If the patient listed multiple concerns, start organizing them with the most severe on top and the least severe at the end. If you have trouble determining which problem is the most severe, ask them what they’re the most concerned with. If there is a clear diagnosis for the problem, list it immediately after the problem on your SOAP note. If there are different causes for the problem, then list them all so the most likely option is the first one. Look at the Subjective and Objective sections of your soap note to speculate what’s causing the patient’s problems. You may not know exactly what’s causing the problems, so make educated guesses based on what you’ve already found. Cite exact reasons from the Subjective and Objective sections of your SOAP note in your diagnoses. If you’re writing descriptions for multiple diagnoses, then be sure to include any that could conflict one another. Always leave a description so other professionals know why you made certain decisions with your treatment.

What is a summary?
Record any changes in the patient’s problems if you’ve seen them before. List the patient’s problems in order of importance. Note any diagnoses that you can make. Write your reasoning for why you chose each diagnosis.