Physician Assistant how-to
How to Write a Clear SOAP Note
Good notes support care and billing.
Quick answer
Good notes support care and billing. In short: record; document; list, then complete the remaining steps below.
Step by step
Record the patient’s story.
Document exam findings.
List test results.
State the assessment.
Write the plan.
Note follow-up and education.
Safety reminders for physician assistants
- Follow infection control and sharps safety
- Verify patient identity and allergies
- Use safe prescribing practices
- Escalate concerns to the collaborating physician
Key terms
PANCE · PA-C · Differential diagnosis · Chief complaint · HPI · SOAP note: see the full physician assistant glossary.