How to do SOAP

What SOAP is

SOAP is the intern note. Four headings. One visit. Nothing extra. Every other document in this studio is the same thinking in a different shape.

1. S
   Subjective

   What the patient tells you. The story in time order — not a transcript, not a textbook.

2. O
   Objective

   What you measured and examined. Vitals, the exam you actually did, labs already back.

3. A
   Assessment

   What you think it is, and why. The worst things it is not, and why.

4. P
   Plan

   What you will do. Numbered orders. Drug, dose, route. Who follows up. Red flags the patient can repeat.

How to do it

1. 1
   One-liner first

   Age, sex, PMH that matters, why they are here. Write it before you write anything else. It is the spine of S and of A.

2. S
   Subjective

   OLDCARTS for the complaint. Pertinent positives and the one negative that kills the worst diagnosis. Quote the patient once if it changes the case. Meds, allergies, and PMH only if they change today’s plan.

3. O
   Objective

   Vitals you took. Exam you performed — focused, not a 14-system normal you copied. Data already resulted. Do not list tests you wish you had.

4. A
   Assessment

   Problem → most likely, because → not this, because. “CHF exacerbation 2/2 dietary sodium, less likely ACS (no CP, troponin negative ×2, ECG unchanged).” A diagnosis list without because is not an assessment.

5. P
   Plan

   Numbered. Diagnostics, therapeutics, consults, disposition. Drug dose route duration. Return precautions in the patient’s language. Never “continue current management.” Never “consider labs.”

The other documents

Same thinking. Different heading. Open Example to see a full page of each.

What you are actually being graded on

US clinical experience is a tryout. The attending is asking: if this person were my intern in July, would the patients be safer?

They do not grade your USMLE score in the workroom. They grade whether you pre-rounded, whether the overnight events are in the note, whether the plan is orders, and whether you can present in under two minutes without reading.

Observer vs extern vs hands-on

Observership: you watch, you may not touch the EMR. You still write the note — on paper or in this studio — and you present it. Ask “may I run the one-liner and A/P by you after rounds?”

Externship / hands-on: you may write, examine, and sometimes place orders under a license. Follow that site’s rules exactly. Never copy a real chart into a practice tool.

If you do not know which you are, ask the coordinator on day one. Getting this wrong is how people get sent home.

A day that earns a letter

Night before: know your 2–4 patients. One-liner, overnight events, today’s numbers, the question you will ask.

Pre-round: vitals, I/O, pain, new complaints, wounds, lines, what the nurse is worried about. Write it down.

Rounds: present, do not perform. One-liner, 3-sentence HPI, deltas, data, A/P. Stop. Let them teach.

After: the note matches what you said, within an hour. One task you own (call a consultant, check a culture, teach a discharge).

End of day: ask for one piece of feedback on one note. Write it down. Do it tomorrow.

How to present (the spoken note)

“Mr Hale is a 64-year-old man with hypertension who presented 90 minutes after last known well with a left MCA syndrome, NIHSS 8. CT is without blood. He is a TNK candidate if we get SBP under 185.”

That is a presentation. What follows is only what changes the plan. Do not read the ROS. Do not say “the patient is a 64-year-old gentleman who lives with his wife and…” unless social facts change disposition.

If you get lost: stop, one-liner again, then A/P. Attendings prefer a short recovery to a five-minute wander.

English that sounds intern-level

Short sentences. US drug names. US units. No “kindly advise.” No “patient was apparently.” No “we shall consider.”

“I think this is pre-renal AKI from ACE + diarrhea. I would hold the lisinopril, give a liter, and I do not see an indication for dialysis today because potassium is 4.6 and he is making urine.”

If a word will not come, say the simple word. Clarity beats vocabulary.

How to take feedback — and how to ask for the letter

After a note: “What would make this intern-level?” Then do only that one thing the next day so they can see the change.

Week three, after they have read your work: “I am applying in [specialty]. Would you be comfortable supporting my application with a letter that can mention [this patient / this skill]?”

Do not ask on day three. Do not ask a person who has not read a note. A weak letter is worse than none.

What actually grades you

Do not

• Day-wise study plans or textbook dumps inside a SOAP.
• Invented labs, scores, or guideline years you did not actually use.
• Real patient identifiers — this studio is fictional practice only.
• Writing in the real EMR if you are an observer and the site forbids it. Practice here; present there.
• Apologizing in the note (“sorry for my English”). Write short sentences instead.