{"id":1754,"date":"2018-12-07T19:54:00","date_gmt":"2018-12-07T19:54:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=1754"},"modified":"2026-01-06T17:01:49","modified_gmt":"2026-01-07T01:01:49","slug":"3-tips-to-write-progress-notes","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes","title":{"rendered":"3 Tips to Write Progress Notes"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Introduction\" >Introduction<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Tip_1_Write_a_Story\" >Tip #1: Write a Story<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Tip_2_Remember_That_a_Diagnosis_Is_a_Label\" >Tip #2: Remember That a Diagnosis Is a Label<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Tip_3_Write_a_Specific_Plan\" >Tip #3: Write a Specific Plan<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Why_are_progress_notes_important\" >Why are progress notes important?<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#As_a_Communication_Tool\" >As a Communication Tool<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#As_a_Legal_Document\" >As a Legal Document<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#As_a_Contract_Between_Patients_and_Health_Professionals\" >As a Contract Between Patients and Health Professionals<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/3-tips-to-write-progress-notes\/#Key_Takeaways\" >Key Takeaways<\/a><\/li><\/ul><\/nav><\/div>\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Introduction\"><\/span>Introduction<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">As a health professional, knowing how to write a <strong>progress note<\/strong> is important. These progress notes are also known as <strong>SOAP notes<\/strong>. Why soap? Well, if you&#8217;ve written a progress note before, you know that SOAP is a <strong>useful shorthand<\/strong> for remembering the <strong>four components of note-taking<\/strong>:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>S<\/strong>ubjective<\/li>\n\n\n\n<li><strong>O<\/strong>bjective<\/li>\n\n\n\n<li><strong>A<\/strong>ssessment<\/li>\n\n\n\n<li><strong>P<\/strong>lan<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Now that we know the four parts, how are they applied in a <strong>clinical setting<\/strong>?<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>The\u00a0subjective\u00a0element of a SOAP note is what the individual shares with their health professional.\u00a0<\/strong><\/li>\n\n\n\n<li><strong>The\u00a0objective\u00a0piece is what the health professional determines through a physical exam, laboratory results, or imaging.\u00a0<\/strong><\/li>\n\n\n\n<li><strong>An\u00a0assessment\u00a0is when the health professional provides a diagnosis.\u00a0<\/strong><\/li>\n\n\n\n<li><strong>The\u00a0plan\u00a0is when the health professional decides what&#8217;s next.<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><em>What makes a great progress note? Here are three tips:<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Tip_1_Write_a_Story\"><\/span>Tip #1: Write a Story<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">When an individual comes to a <strong>health professional with a problem<\/strong>, they will begin to <strong>describe their experience<\/strong>. For example, the individual might complain of <strong>worsening hip pain<\/strong>. It&#8217;s the <strong>health professional&#8217;s job<\/strong> to determine the <strong>potential cause<\/strong> of that pain. In listening to the individual&#8217;s <strong>subjective experience<\/strong>, it&#8217;s helpful to <strong>ask questions<\/strong> and <strong>establish the proper order of the story<\/strong>. In the case of the individual with hip pain, the health professional might discover a <strong>visit to the gym preceded the injury<\/strong>. <strong>Now we have a clue!<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">At first, the individual&#8217;s story might be a bit <strong>out of order<\/strong>. In describing their pain, the person may only be describing bits of the story. During the history and physical exam, it&#8217;s important that the <strong>health professional lays out a story that makes sense<\/strong>. So, in the above example, the health professional would establish that the <strong>gym may have preceded the onset of the pain<\/strong> and supplement this information with their findings during the physical exam.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You want to <strong>tell a good story<\/strong>, and you want it to <strong>make logical sense<\/strong>. This story should <strong>build up to a crescendo<\/strong>, which is the <strong>assessment<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Tip_2_Remember_That_a_Diagnosis_Is_a_Label\"><\/span>Tip #2: Remember That a Diagnosis Is a Label<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">In writing the assessment, it&#8217;s important to remember that the <strong>diagnosis will stick with the individual<\/strong> over the course of many medical appointments. Let&#8217;s say a health professional has suggested the individual is <strong>depressed<\/strong>. That written <strong>label is not easy to shake off<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For example, this individual might be <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Vitamin_B12_deficiency\">vitamin B12 deficient<\/a><\/strong>, but discovering this diagnosis is prevented by what appears in the progress note. In this case, <strong>&#8220;Diagnosis: Depression&#8221;<\/strong> can make it difficult to correctly assess the issue. Every time the patient says, <strong>&#8220;I feel fatigued or tired,&#8221;<\/strong> the response will be, <strong>&#8220;You&#8217;re depressed.&#8221;<\/strong> Remember, when you write your <strong>diagnosis<\/strong>, other health professionals will see that label. It&#8217;s possible to <strong>cheat the individual out of getting the real diagnosis<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Establish your uncertainty in writing.<\/strong> If you&#8217;re not sure about something, add that to your <strong>assessment<\/strong>. <strong>Use modifiers:<\/strong> &#8220;This seems possibly to be depression, but other things we should consider would be: <a href=\"https:\/\/www.osmosis.org\/learn\/Hypothyroidism\">hypothyroidism<\/a> or vitamin B12 deficiency.&#8221;<\/p>\n\n\n\n<figure class=\"wp-block-image alignleft size-large is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"400\" height=\"310\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/mo-doc.png?w=400\" alt=\"\" class=\"wp-image-5539\" style=\"width:225px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/mo-doc.png 400w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/mo-doc.png?resize=300,233 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Tip_3_Write_a_Specific_Plan\"><\/span>Tip #3: Write a Specific Plan<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The plan is the <strong>final part of the SOAP note<\/strong>. In writing the plan, it&#8217;s important to be <strong>specific<\/strong>. For example, something like <strong>&#8220;Plan to lose weight&#8221;<\/strong> is not very helpful. Instead, it&#8217;s useful to aim for something like <strong>&#8220;Reduce soda from three times a week to one time a week&#8221;<\/strong> or <strong>&#8220;Start drinking a healthy smoothie for breakfast.&#8221;<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Why_are_progress_notes_important\"><\/span>Why are progress notes important?<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A SOAP note serves three important functions: a communication tool, a legal document, and a contract between the patient and provider.<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"As_a_Communication_Tool\"><\/span>As a Communication Tool<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">A progress note is a way to <strong>communicate with other health professionals<\/strong>. The <strong>subjective, objective, assessment, and plan<\/strong> components of the note will <strong>inform the individual&#8217;s treatment<\/strong> during other medical visits. We also know that <strong>insurance companies want to see these SOAP notes<\/strong>.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"As_a_Legal_Document\"><\/span>As a Legal Document<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">A SOAP note is also a <strong>legal document<\/strong> between the <strong>health professional and insurance companies<\/strong>.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"As_a_Contract_Between_Patients_and_Health_Professionals\"><\/span>As a Contract Between Patients and Health Professionals<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Last but not least, a SOAP note serves as a <strong>contract between the health professional and the patient<\/strong> or other individual seeking help. It&#8217;s an <strong>important tool for establishing a shared understanding<\/strong> of the <strong>potential problem<\/strong>, and the <strong>pathway to good health<\/strong>. Be <strong>as specific as possible<\/strong> in this contract.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Key_Takeaways\"><\/span>Key Takeaways<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>SOAP stands for Subjective, Objective, Assessment, and Plan.<\/strong><\/li>\n\n\n\n<li><strong>A good progress note tells a clear, logical story.<\/strong><\/li>\n\n\n\n<li><strong>Be cautious with diagnostic labels; they can influence future care.<\/strong><\/li>\n\n\n\n<li><strong>Write a specific, measurable plan for the patient.<\/strong><\/li>\n\n\n\n<li><strong>SOAP notes serve as communication, legal, and care contracts.<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Now, let&#8217;s SOAP up those hands and get to writing!<\/em><strong><a href=\"https:\/\/www.osmosis.org\/plans\/md?source_cta=blog-navbar\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/md?source_cta=blog-navbar\"><img loading=\"lazy\" decoding=\"async\" width=\"994\" height=\"356\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_04dd2b.png?w=994\" alt=\"\" class=\"wp-image-1696\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_04dd2b.png 994w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_04dd2b.png?resize=300,107 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_04dd2b.png?resize=768,275 768w\" sizes=\"auto, (max-width: 994px) 100vw, 994px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>f<\/strong><\/a><a href=\"https:\/\/www.osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>ree trial<\/strong><\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Discover how to write an effective SOAP progress note that tells the patient\u2019s story clearly, communicates accurately with colleagues, and builds trust; all while avoiding common documentation mistakes.<\/p>\n","protected":false},"author":228,"featured_media":1755,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,6,5,10,867,30,16,37,32,43],"tags":[2066,343,936,2064,2067,2060,2065,2059,2058,2061,149,2062,410,2063,216],"class_list":["post-1754","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-career-advice","category-clerkships","category-clinical-skills","category-lpn","category-np","category-do","category-pa","category-nursing","category-residency","tag-charting","tag-clinical-assessment","tag-clinical-documentation","tag-diagnosis-tips","tag-documentation-guide","tag-health-professionals","tag-healthcare-best-practices","tag-healthcare-writing","tag-medical-communication","tag-medical-records","tag-patient-care","tag-progress-notes","tag-soap-notes","tag-treatment-planning","tag-writing-skills"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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