Progress SOAP Note
The daily note, in the order you will present it on rounds, with three worked examples you can steal the structure from.
The daily progress note is the most written and least read document in the hospital. It gets read at three in the morning by a cross-cover intern who has never met your patient and has ninety seconds to decide whether the tachycardia is new. It is also read by the consultant, the pharmacist, the case manager and eventually a lawyer. A good note answers three questions in under a page: what changed since yesterday, what do you think it means, and what are you doing about it today. The admission history and physical holds the story. The daily note is the delta.
The skeleton S O A P
Patient comments or complaints. Nursing comments. What happened overnight.
Vitals: blood pressure, pulse, respirations, temperature, weight, oxygen saturation.
Ins and outs: IV fluid, oral intake, emesis, urine, stool, drains.
Exam: physical findings.
Meds: pertinent routine or new medications.
Labs: new laboratory or procedure results. Not old information, just the most recent.
Assessments based on the data above.
Medication changes, lab tests, procedures, consults, discharge planning.
S Subjective
Three voices belong here, and they are not interchangeable.
The patient, in their words, about the thing you are treating. "I lay flat last night." "I still cannot reach the bathroom without stopping." In heart failure and COPD that beats anything you will measure.
The nurse, who was there twelve hours to your four minutes. Ask before you write. She will tell you he pulled the cannula off twice or was confused only at night.
Overnight events. Rapid response, a bolus, a fall, a held med, an order from cross-cover. If the night team did something, say what and why.
It means either the patient is fine or you did not ask, and the reader cannot tell which. It is the daily-note version of "non-contributory."
Write what you asked and what you got. "Denies chest pain, orthopnea or PND. Says his breathing is the best it has been since he came in." Same typing, and defensible six months later.
O Objective
Vitals, in a fixed order
Temperature and Tmax, heart rate, blood pressure, respiratory rate, saturation and on what, then weight. Same order every day so the reader's eye knows where to land. Give ranges, not the 6 a.m. snapshot: "HR 104 to 118" says something "HR 110" does not. Name the oxygen device, because 92 percent on room air and 92 percent on a non-rebreather are different patients.
The weight
Keep the weight on the note every day for anyone you are diuresing. It is the single most useful number in heart failure and it is the one people leave out. A kilogram is a liter. If you have given 80 mg of IV furosemide twice a day for three days and the weight has not moved, either the drug is not working, the patient is drinking, or nobody is weighing them. Same scale, same time, before breakfast.
Ins and outs, including drains
Twenty-four hour totals and the running total since admission. Intake includes the piggybacks, which can be a liter a day nobody counts. Output is urine, stool, emesis and every drain by name: chest tube, JP, NG, ostomy, wound vac. Give character, not just volume. "JP 40 mL serosanguineous" and "JP 40 mL bloody" are different notes. Keep your own tally on a patient tracker sheet if the flowsheet is unreliable.
A focused exam, not a copied one
Yesterday's exam pasted forward is worse than no exam, because it is a false statement about a real patient. Examine what the problem list demands. Heart failure: JVP with the bed angle, bases, S3, edema level. COPD: words per sentence, accessory muscles, air movement. Post-op: incision, drain, abdomen, calves. "Edema 1+ to mid-shin, was 3+ to the knees" is an exam and a trend in one line.
Meds and labs
Not the full MAR. The drugs treating the active problems, with dose, route and day number: "prednisone 40 mg PO daily, day 3 of 5." Day numbers are how the reader knows when to stop. Note anything held and why.
Labs go in as trends, never snapshots. Write the value with the two before it: "creatinine 1.4 (1.2, 1.2)," "WBC 15.2 (12.8, 11.1)." A creatinine of 1.4 is reassuring falling and alarming rising, and your note should not send the reader to the lab tab to find out which. New results only.
A Assessment
This is the part you are paid for, and most people skip it by retyping the admitting diagnosis. "52 year old female with pyelonephritis" is a label, not an assessment. The reader already knew it.
The assessment is a numbered problem list, most acute first, and every problem gets three things: what it is, whether it is better, worse or unchanged, and why you think so.
The shape of an assessment line
Acute decompensated HFrEF, EF 25 percent, congestion resolving. Net minus 5.9 L and 4.3 kg in two days. The creatinine bump with a rising BUN to creatinine ratio and rising bicarbonate is hemoconcentration from effective decongestion, not injury. Still congested by JVP and edema, so I am not backing off.
The reasoning is visible, so anyone who disagrees knows where to disagree. "Creatinine up, will monitor" gives them nothing to argue with and nothing to trust. Resolved problems get said once, on the day they resolve, then come off the list.
P Plan
One plan per problem, numbered to match the assessment. If problem 3 has no plan, problem 3 does not belong on the list.
A plan is an action with a number attached. "Continue diuresis" is not a plan. "Furosemide 80 mg IV q12h, target 1.5 to 2 L negative, BMP in the morning, drop to 40 mg if the creatinine passes 1.8" is a plan, and it lets the night resident act without paging you. Put a disposition line on every note from day one, because case management reads that line and nothing else.
Example 1 CHF exacerbation, hospital day 2, diuresing well
71 year old man, acute decompensated HFrEF, HD 2
S: Lay flat for the first time in a week. Up to the bathroom twice without getting winded. No chest pain or PND. Night nurse: voided every two hours after the evening furosemide, asked for a salt packet at dinner. No overnight events.
O: T 36.8. HR 78, was 96 on admission. BP 108/64, was 124/78. RR 18. SpO2 94 percent on room air, off 2 L since 2200. Weight 84.1 kg, from 86.0 yesterday and 88.4 on admission.
Ins and outs: in 640 mL PO, out 3,850 mL urine, net minus 3,210. Since admission minus 5,900. Foley out yesterday, no drains.
Exam: JVP 8 cm at 45 degrees, was 14. Few bibasilar crackles. S3 present, 2/6 apical murmur unchanged. Edema 1+ to mid-shin, was 3+ to the knees. Warm, refill 2 seconds.
Meds: furosemide 80 mg IV q12h, day 2. Carvedilol 3.125 mg PO BID. Spironolactone 12.5 mg PO daily, day 2. KCl 40 mEq PO daily. Lisinopril held for the creatinine.
Labs: Na 136 (138, 140). K 3.6 (4.1, 4.4). Creatinine 1.4 (1.2, 1.2). BUN 34 (26, 22). Bicarb 30 (26, 25). Mg 1.8.
A/P:
- Acute decompensated HFrEF, EF 25 percent, congestion resolving. The creatinine rise with a widening BUN to creatinine ratio and rising bicarbonate is hemoconcentration, not injury, and he is still congested. Continue furosemide 80 mg IV q12h, target another 1.5 to 2 L negative. Daily weight before breakfast, strict ins and outs, BMP in the morning. Drop to 40 mg if the creatinine passes 1.8 or the JVP normalizes. Fluid restrict 1.5 L, 2 g sodium, dietitian today.
- Hypokalemia and low magnesium from loop diuresis. KCl 40 mEq PO now, standing dose up to 40 mEq BID. Magnesium sulfate 2 g IV once. Recheck K and Mg at 1600.
- Mild contraction alkalosis. Expected, not limiting therapy. Follow on the morning BMP.
- CKD stage 3, at baseline. Hold lisinopril one more day, restart at 2.5 mg once the creatinine is flat so he leaves on guideline therapy.
Disposition: one to two more days of IV diuresis, then torsemide 20 mg PO daily observed a day. Home with a weight log and a 2 kg call-in threshold.
Example 2 COPD exacerbation, hospital day 3, not improving
The note that matters most is the one where the patient is not getting better, because that is the note where you admit the plan is wrong. Interns write this note worst.
64 year old woman, AECOPD, HD 3
S: Says she is "about the same." Pushed on it, that means she still cannot reach the bathroom without stopping, unchanged from yesterday. Cough now productive of thick green sputum. Slept sitting up. RT gave extra albuterol at 0200 and 0430. Nurse reports she pulled the cannula off twice and desaturated to 84 percent.
O: Tmax 38.1 at 0400, now 37.6. HR 104 to 118. BP 138/82. RR 24 to 28. SpO2 90 percent on 4 L, was 92 percent on 2 L yesterday. Weight 61 kg, unchanged. In 1,200 mL PO, out 900 mL urine, net plus 300. No drains.
Exam: tripoding at the edge of the bed. Four word sentences, were six to eight yesterday. Accessory muscle use at the neck. Poor air movement, diffuse expiratory wheeze. New coarse crackles at the right base. No JVD, no edema, no asterixis.
Meds: prednisone 40 mg PO daily, day 3 of 5. Azithromycin 250 mg PO daily, day 3. Albuterol and ipratropium neb q4h plus q2h PRN, and she has taken every PRN for 48 hours. Tiotropium daily.
Labs: WBC 15.2 (12.8, 11.1), 82 percent neutrophils. ABG on 4 L: pH 7.31, pCO2 62, pO2 61, HCO3 30. Yesterday on 2 L: 7.36, 54, 68, 30. Chest film: new right lower lobe opacity, not on the admission film. Sputum gram stain gram positive diplococci. Blood cultures negative at 48 hours.
A/P:
- AECOPD, failing the current plan on day 3. She is worse, not plateaued: pH 7.31 from 7.36, pCO2 up 8, fewer words per sentence, more oxygen for a lower saturation. Complete prednisone through day 5, continue duonebs. The reason she is failing is problem 2.
- New right lower lobe pneumonia, likely pneumococcal. New infiltrate, rising white count, new fever, gram positive diplococci. Azithromycin alone does not cover this. Add ceftriaxone 1 g IV daily. Send sputum culture and urine pneumococcal and legionella antigens.
- Impending hypercapnic respiratory failure. Start noninvasive ventilation now at 12/5, titrate to a rate under 24. Repeat ABG one hour after starting. Transfer to step-down. If the pH falls below 7.25 or she tires, intubate rather than persisting. ICU aware.
- Hypoxia with poor cannula tolerance. Target saturation 88 to 92 percent, no higher. Reinforce with her why the oxygen stays on.
- Goals of care. Discussed with her and her daughter this morning. She wants a trial of noninvasive ventilation and is willing to be intubated if it fails. Full code, confirmed today.
- Tobacco use disorder. Nicotine patch 21 mg daily, cessation counseling before discharge.
Disposition: no discharge planning today. Reassess after the post-BiPAP gas. Family updated at 0730.
A note reading "continues on treatment for COPD exacerbation" on day 3, day 4 and day 5 of a patient quietly heading toward intubation is the one that gets read out loud at the morbidity and mortality conference. If the plan is not working, write that it is not working and what you changed.
Example 3 Post-operative day 1
58 year old man, POD 1 laparoscopic sigmoid colectomy for recurrent diverticulitis
S: Incisional pain 6 out of 10 with movement, 3 at rest. Two doses of oxycodone overnight. No nausea, no flatus yet. Took clear liquids at 0600 and kept them down. Up to the chair with PT for 30 minutes. Night nurse reports urine output fell to 20 mL per hour from 0200 to 0500, she gave a 500 mL lactated Ringer's bolus per the post-op orders, and output returned to 60 mL per hour.
O: Tmax 37.9 at 0200, now 37.2. HR 92, was 78 to 88. BP 118/70. RR 16. SpO2 96 percent room air. Weight 92 kg, up 2.4 kg from pre-op.
Ins and outs since the OR: in 3,200 mL crystalloid including the bolus, out 1,150 mL urine and 40 mL from the left lower quadrant JP, serosanguineous, not feculent. Blood loss 75 mL. Net plus 2,000 mL.
Exam: comfortable at rest. Bases decreased, incentive spirometry only 750 mL. Abdomen soft, mildly distended, appropriately tender at the port sites, hypoactive bowel sounds, no rebound or guarding. Incisions clean and dry. JP site clean. Calves nontender, compression devices on.
Meds: acetaminophen 1 g IV q6h scheduled, ketorolac 15 mg IV q6h, oxycodone 5 mg PO q4h PRN. Enoxaparin 40 mg SC daily, started last evening. No post-op antibiotics, single pre-op cefazolin dose only.
Labs: Hgb 11.8 (13.9 pre-op). WBC 13.4 (8.2 pre-op). K 3.4. Creatinine 0.9, baseline 0.9. Lactate 1.4.
A/P:
- POD 1 laparoscopic sigmoid colectomy, on track. The tachycardia and the transient oliguria both answered volume and fit third spacing rather than bleeding: benign abdomen, serosanguineous drain, a hemoglobin drop proportionate to 3.2 L of crystalloid, normal lactate. The white count is the expected surgical stress response and I am not chasing it. Lactated Ringer's at 75 mL/h, no further boluses unless urine output is under 0.5 mL/kg/h for two hours. CBC and BMP in the morning, sooner if the heart rate passes 110 or the drain turns bloody.
- Expected post-op ileus. Advance to full liquids per the ERAS pathway, gum three times a day, chair for all meals, ambulate three times today. JP to bulb suction, output each shift, remove once under 30 mL per 24 hours.
- Post-op fever at 12 hours, atelectasis pattern. No source on exam, incisions clean, no line issues. Not culturing today. Incentive spirometry 10 times an hour while awake, RT to review technique. Reassess if the temperature passes 38.5.
- Post-operative pain, controlled. Continue scheduled acetaminophen and ketorolac, ketorolac limited to 48 hours. Convert to oral only once he is on full liquids.
- VTE prophylaxis. Enoxaparin 40 mg SC daily and compression devices, both confirmed on exam.
- Mild hypokalemia. KCl 40 mEq PO once, recheck with morning labs.
Disposition: discharge POD 3 to 4 once passing flatus, tolerating diet and controlled on oral analgesia. Discharge summary started today so it is not written from scratch at 5 p.m. on a Friday.
Bad note versus good note Same patient, same day
52 year old woman, hospital day 3, pyelonephritis with bacteremia.
The copy-forward version
S: No complaints. Patient seen and examined.
O: Afebrile, vital signs stable. Heart regular rate and rhythm. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Extremities no edema. Labs reviewed.
A: 52 year old female with pyelonephritis.
P: Continue current management. Continue IV antibiotics. Follow up cultures. PT and OT. Discharge planning.
Forty words and no information. It does not say she is better, and it does not name the antibiotic, the day or the stop date. "Afebrile" is false, since she spiked to 37.8 last night. "Labs reviewed" is a claim, not a finding.
The real note
S: Fever curve broke overnight, first 24 hours without a temperature above 38. Flank pain 2 out of 10, was 7 on admission. Ate most of breakfast. Nurse reports she walked the hall twice unassisted. No dysuria today.
O: Tmax 37.8 at 1900 yesterday, none since. HR 82, was 112 on admission. BP 116/72. RR 16. SpO2 98 percent room air. In 1,800 mL PO, out 2,100 mL. No drains.
Exam: right costovertebral angle tenderness still present but she no longer guards against it. Abdomen soft. Peripheral IV site clean, no phlebitis.
Meds: ceftriaxone 1 g IV daily, day 3.
Labs: WBC 9.8 (14.2, 18.6). Creatinine 0.9 (1.1, 1.6), baseline 0.9. Admission blood cultures E. coli, sensitive to ciprofloxacin. Urine culture the same organism.
A/P:
- Acute pyelonephritis with E. coli bacteremia, responding. Afebrile 24 hours, white count normal, heart rate down 30, pain 7 to 2, and the sensitivities allow oral step-down. Change ceftriaxone to ciprofloxacin 500 mg PO BID this morning and watch a day on oral therapy. Ten days total from the first effective dose, so through the 14th. Pull the peripheral IV tomorrow if she stays afebrile.
- Prerenal AKI, resolved. Creatinine back to baseline after volume. Stop maintenance fluids, encourage oral intake, BMP in the morning and then stop checking.
Disposition: home tomorrow if she stays afebrile on oral therapy. Independent at baseline, does not need PT.
The good note is longer, but not by much, and every line is load-bearing. The intern reading it at 3 a.m. knows the drug, the day, the stop date and what getting worse would look like.
What to cut Delete these today
- The full review of systems. It belongs on the admission H&P. Nobody performs a 14 system review on day 4, and a note claiming you did is a note claiming something untrue.
- The unchanged past medical history. It is already in the chart, once, correctly. Retyping it every morning buries the two lines that matter today.
- The complete medication list. Twenty-two lines pasted from the MAR does not say what you are treating with. Four lines with day numbers does.
- "Will continue current management." The laziest sentence in hospital medicine. No drug, no dose, no duration, no endpoint, and worthless in a deposition.
- Bulk lab tables. Pasting 48 hours of results is not interpreting them. Pick the ones that moved.
Cutting that takes a two page note down to half a page, and the half page gets read.
The note versus the presentation Two different products
The note is a record. The presentation is a request for a decision. Reading your note out loud is the most common way students fail on rounds.
| Element | The note | The presentation |
|---|---|---|
| Length | Half a page | 60 to 90 seconds |
| Vitals | All of them, as ranges | Only what changed |
| Labs | Values with trends | The pattern, not the numbers |
| Exam | Focused findings, written | Only what alters the plan |
| Assessment | Reasoning spelled out | Conclusion first, reasoning if challenged |
| Plan | Every problem | What you want permission to do |
Write the note so it stands alone for a stranger. Speak the presentation so it moves a decision. For the spoken version, see how to present a patient on rounds.
Copy-forward risk Where notes become evidence
Copying forward is how a resolved problem stays on the list for nine days and how a wrong medication survives three services. Rewrite the assessment every morning. If a problem is resolved, say so and take it off.
The EHR will reproduce yesterday's note in one keystroke, including the exam you did not do, the foley that came out on Tuesday, and "patient remains intubated" on a patient extubated two days ago. Each is a false statement in a legal document with your name on it, and they are trivial to find, because the identical paragraph appears nine times with nine different dates.
Reread every line you pull forward before you sign. You are attesting that all of it is true today, and anything you would not say under oath comes out. More in the guide to charting and medical legal risk.
Get the printable tracker sheet pack
These are the printable PDF scut sheets we use on the wards: admit sheets and daily progress notes laid out in the exact order you present on rounds, patient trackers with an active problem list and separate columns for home and hospital medications, a ten patient sheet for bigger lists, and a cardiology and telemetry note. Print them double sided, fold them into your pocket, and stop rewriting the same information three times a day.
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This is not medical advice. The drugs, doses and thresholds below are illustrative, written to show the shape of clinical reasoning. Local policy, your attending and current references govern actual care.