Most of us learned SOAP notes as housemen and then quietly drifted into our own shorthand. That works until a colleague has to pick up the patient, an insurer asks for the record, or a complaint lands two years later. Here is how to write a SOAP note that is quick to produce and still does its job.
Updated 19 October 2026.
A SOAP note records a consultation in four parts: Subjective (what the patient tells you), Objective (what you find), Assessment (what you think is going on) and Plan (what happens next). It grew out of Lawrence Weed's problem-oriented medical record in the late 1960s and is still the default structure for outpatient notes worldwide.
No Malaysian rule requires the SOAP format by name. But the Malaysian Medical Council's guideline on medical records says a record should "support the diagnosis based on history, physical examination and investigations, justify the professional management given" and "ensure the continuity of care". A well-written SOAP note does exactly that, which is why it remains the safest everyday format for a Malaysian clinic.
| Section | What it holds | Common gap |
|---|---|---|
| Subjective | Presenting complaint, history of the complaint, relevant past history, medications, allergies, and what the patient or parent is worried about. | Allergies and current medicines not recorded, or the patient's actual concern missing. |
| Objective | Vital signs, examination findings, test results available at the visit, and measurements such as weight for children. | "Chest clear" with no vitals, or findings mixed into the history. |
| Assessment | Your working diagnosis or problem list, the differentials you considered, and your reasoning. | A diagnosis label with no reasoning, so the next doctor cannot see why. |
| Plan | Investigations, treatment with doses, advice given, safety-netting, MC or referral, and when to return. | No follow-up or red-flag advice recorded, which is what matters most if the patient worsens. |
Write the Subjective in the patient's terms where it helps. "Sakit tekak since Friday, worse at night" is clearer than a translated summary, and it shows you listened. Keep your own interpretation for the Assessment.
A routine adult visit at a GP clinic. This is an illustration of structure only, not clinical guidance.
S: 34-year-old woman, 3 days of sore throat and runny nose, mild dry cough. Low-grade fever at home, highest 37.9°C. Eating and drinking normally. No shortness of breath, no rash. Works in an office. No chronic illness. No regular medicines. No known drug allergy. Worried she needs antibiotics before a work trip on Thursday.
O: Alert, comfortable. Temp 37.6°C, pulse 88, BP 118/76, SpO2 99% on room air. Pharynx mildly injected, no exudate. No cervical lymphadenopathy. Chest clear, good air entry bilaterally.
A: Acute upper respiratory tract infection, most likely viral. No features suggesting bacterial tonsillitis or lower respiratory involvement. Antibiotics not indicated at present.
P: Explained likely viral cause and expected course of 7 to 10 days. Paracetamol 1 g up to four times a day as needed. Fluids and rest. MC 2 days (19 to 20 Oct). Return or seek care if breathing difficulty, fever beyond 5 days, unable to swallow fluids, or worsening after initial improvement. Patient understood and agreed.
Notice what makes it useful. A locum reading it next week knows what was found, what was ruled out, why there were no antibiotics, and what the patient was told to watch for. If the patient returns with pneumonia, the note shows a reasonable assessment at the time.
The Council's guideline on records is MMC Guideline 002/2006, Medical Records and Medical Reports, adopted on 14 November 2006. It does not prescribe a format, but several of its expectations apply directly to how you write SOAP notes:
The guideline was written with paper continuation sheets in mind, but it does recognise computerised records. The same principles carry over to an electronic system: entries tied to a user and a time, and amendments that leave the original visible. It also reminds doctors that a record "can be demanded by the patient and the courts of law in matters of litigation". For how long to keep notes once written, see our guide on medical records retention in Malaysia.
SOAP is not the only option, and it does not suit every visit equally well.
Whichever you use, keep it consistent within the clinic. A locum or a colleague covering leave should know where to look for the plan without reading the whole note.
The real problem in most Malaysian clinics is not knowing what a SOAP note should contain. It is time. A full list with complex patients leaves little room to write properly, so notes shrink. Some things that help:
We built Catat for that last option. It listens to a consultation in Manglish, BM or English and drafts a structured SOAP note, MC and patient letter. It is currently running as a pilot with paediatric clinics. Whatever tool drafts the note, you remain responsible for it: read it, correct it and sign it as your own. Our guide to AI medical scribes covers what to check before adopting one.
Sources: MMC Guideline 002/2006, Medical Records and Medical Reports, sections 1.1 to 1.6. Lawrence Weed, "Medical Records that Guide and Teach", New England Journal of Medicine 1968; 278:593 to 600. George Dunea, Problems with medical records, Hektoen International (2015). Bob Wachter, Putting the "A" Back in SOAP Notes, The Hospital Leader (2012). The clinical example is illustrative only and is not treatment guidance.
SOAP stands for Subjective, Objective, Assessment and Plan. Subjective is what the patient or parent tells you. Objective is what you observe and measure, such as vital signs and examination findings. Assessment is your diagnosis or problem list with your reasoning. Plan covers investigations, treatment, advice, MC or referral, and follow-up. The format grew out of Lawrence Weed's problem-oriented medical record in the late 1960s.
No Malaysian rule requires SOAP by name. The MMC's Guideline 002/2006 on medical records asks for a record that identifies the patient, supports the diagnosis from history, examination and investigations, justifies the management and ensures continuity of care. SOAP is the most common way to meet that standard in outpatient practice, so most clinics and training programmes use it.
They contain the same four parts in a different order. APSO puts the Assessment and Plan at the top, followed by Subjective and Objective. Some clinicians prefer APSO because the next reader sees the conclusion first without scrolling. Neither is more correct. What matters is that the clinic uses one format consistently so colleagues know where to find the plan.
Sparingly. The MMC guideline says abbreviations and short forms should generally be avoided, and if used should be ones traditionally accepted and recognised by healthcare staff. The same abbreviation can mean different things in different specialties, such as PID. If a reader from another discipline might be unsure, write the term in full. A clinic-approved abbreviation list helps keep usage consistent.
An AI scribe can draft a SOAP note from the consultation, but the note is still yours. You need to read it, correct anything wrong or missing, and sign it, because the MMC expects the record to reflect your own findings and management. Check how the tool handles patient data and recordings before you adopt it. Catat, our AI scribe, is currently a pilot for paediatric clinics.
Catat drafts a structured SOAP note, MC and patient letter from a consultation in Manglish, BM or English, ready for you to review and sign. It is currently a pilot for paediatric clinics.
See how Catat works →