Glossary, documentation
What is a SOAP note?
A SOAP note is a structured clinical note in four parts, subjective (what the patient reports), objective (examination findings and results), assessment (the clinician's diagnosis or impression) and plan (treatment, tests, referrals and follow-up). It is one of the most widely used formats for recording a consultation, because any clinician reading it finds the reasoning in the same place.
Updated . Defined by the wai team for clinics, groups and health systems.
Also called SOAP format, subjective, objective, assessment or plan.
Why SOAP note matters to a clinic
A note in a predictable structure is faster to read and harder to misread. A covering clinician, an insurer reviewing a claim or an inspector sampling records can see what was found, what was decided and what happens next.
The plan carries the most risk. Follow-up, safety-netting advice and referrals written there are what the patient relies on after they leave, and what the clinic is asked about if something goes wrong.
Many specialties adapt the format, adding history, red flags or a problem list. The value lies in one structure used consistently across a clinic, so every clinician's notes read the same way.
Questions
What does SOAP stand for?
Subjective, objective, assessment and plan. The four parts move from what the patient reports, to what the clinician finds, to what it means and what happens next.
Can an AI scribe write a SOAP note?
Yes. An AI scribe drafts the note in the structure the clinician chooses, and the clinician reads, edits and signs it. See the wai scribe.
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