SOAP Note: Structure and Sections
Everyday visit note (Subjective, Objective, Assessment, Plan). Notermed's built-in SOAP Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the SOAP Note contains
4 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Subjective
- What the patient reports
- The history given during the visit
- 2
Objective
- Vital signs and measurements
- Examination findings
- Results reviewed
- 3
Assessment
- The clinician impression or diagnosis
- 4
Plan
- Treatment, tests, referrals, and follow-up
Questions about the SOAP Note
What sections does a SOAP note contain?
Four, in this order: Subjective, Objective, Assessment and Plan. Subjective carries what the patient reports and the history given during the visit. Objective carries vital signs and measurements, examination findings and results reviewed. Assessment is the clinician impression or diagnosis. Plan covers treatment, tests, referrals and follow-up.
Does Notermed write the SOAP note automatically?
It writes the draft. Notermed listens to the visit and builds the four sections from what was actually said, then hands the draft to you. You change anything you want changed and sign it, and until you sign it the note is a draft and sits outside the record.
Who signs the note?
You do. Notermed does not sign notes and does not put anything into the record on its own. Every note is a draft until the clinician reviews it and signs it, and the clinician who signs it remains responsible for what it says.
Do I need to install anything to record a visit?
No. You can record in the browser on the computer you already use, and there is an Android app for recording away from the desk. The draft comes back in the same four sections either way.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the SOAP Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.