Using the soap format in English for medical purposes
Novo Rosas y Cecilia
Assistant Professors in "Dr. Salvador Allende"
Faculty at Havana Medical University.
Havana City, Cuba
of the main objectives of teaching English for Medical
Purposes (EMP) is that of providing tools to understand
and use authentic documents used in real professional
settings. This includes not only the standard documentation
(patient's charts, lab orders, prescriptions, etc.),
but also the formats and methods of employing them.
One such format is the SOAP; an acronym for a specific
style of documentation that is often referred to as
SOAP is the brief, clear, communication of the complaint,
physical exam with pertinent positives and negatives,
evaluation of the data, assessment and clinical plan;
commonly stated in short notes containing abbreviations
and symbols standard to all English-speaking countries.
Why have we used it in our English lessons?
of all, it is the most widely used format in most countries
where English is spoken, so our students may benefit by
knowing how to use it, not only with the view of future
medical collaboration, but also the understanding of articles
and cases published in several magazines and Internet
sites. Secondly, it helps to develop thought processes
and study skills (such as listening, asking questions,
taking down notes, stating points of view, summarizing
using data appropriately, and recording results). And
thirdly, it allows to integrate the four skills of the
language (listening, speaking, reading and writing).
Our students have been able to use this format in EMP
activities carried out in our faculty like training on
the job (where the students can be asked to interview
a patient, take down notes and come up with their tentative
diagnoses and management plans), simulations (as in doctor-patient
interviews), case presentations, and review lessons.
We would also like you to know that the SOAP format is
not the only type of medical documentation there is. There
are other several methods used and sometimes modified
by many institutions to meet their specific needs.
such method is the so-called narrative which is just the
same SOAP information, but written in paragraph form (no
notes are allowed). Another type is T.R.P. which stands
for Treatment, Response, and Plan.
This one is said to be used less frequently.
popular method is P.O.M.R., an acronym for Problem
Oriented Medical Record. This one
emphasizes on the problems of the patient and the SOAP
format was initially part of it.
finally, the fastest way to take down a medical history
is by means of the key word SAMPLE PQRST. This stands
for Symptoms, Allergies, Medicine
taken, Past history of similar events, Last
meal, Events leading up to illness or injury; Provocation,
Position, Quality, Radiation, Severity,
Symptoms, Timing, Triggering factors.
you are interested in learning a little more about the SOAP
format, here we include its components according to what each
letter stands for. The letters in the acronym SOAP stand for
Subjective, Objective, Assessment and
Plan. Sometimes the letters ER are added (SOAPER) to
include patient Education and Referral and/or
This section includes what the patient tells you.
complaint (CC)- The patient's reason for coming to see you,
usually summarized in one sentence. E.g.. CC: pt. c/o generalized
aches and pains.
symptoms- E.g.. coughing, fever, swollen glands, weakness,
of symptoms- E.g.. 3/7 (for three days ).
new symptoms which have appeared or prior symptoms noted-
E.g.. headaches 4/7 associated with vomiting.
that makes the symptoms better or worse, aggravates or relieves
the problem- E.g.. lying down for a while relieves the headaches.
of symptoms- E.g.. daily headaches.
already taken- E.g.. aspirin, acetaminophen, etc - state
if they were effective or ineffective.
events (also known as precipitating events)- E.g.. went
camping a week ago.
of symptoms- rate pain as to severity and quality. E.g..
severe and throbbing headaches.
of symptoms- E.g.. bilateral headaches, also pain in the
joints and muscles.
negatives- E.g.. no neck stiffness.
currently taken- E.g.. takes an aspirin a day.
the ones known by the patient, also the effect it caused.
E.g.. ask for the patient's vaccination record.
medical history- E.g.. surgeries, hospitalizations, history
of certain diseases, etc.
This section includes the measurable and pertinent findings
obtained from the physical examination and the diagnostic
tests or procedures.
Examination- Inspection, palpation, percussion, auscultation.
Includes vital signs and the review of systems.
procedures- E.g.. lumbar puncture
tests - E.g.. laboratory tests (CBC, blood culture), X-rays,
This one includes a short tentative diagnosis based on the
information obtained in the subjective and objective sections.
tentative diagnoses for each relevant problem.
of differential diagnoses.
(with different choices).
This component shows your decision-making.
plans (medications given, change in medications, treatment
prescribed specifying dosage, etc.)
diagnostic tests which might be needed. Also include follow-up
to perform surgical procedures.
education (explanation about the problem he/she has, self-care,
understanding of the treatment to follow, etc.)
at a glance
As you have probably noticed the SOAP format includes the
same elements you deal with in your daily lessons, only that
their arrangement is different. We include a comparison of
the Classical Medical Format (similar to the one used in our
country) and the SOAP Format to give a better idea.
do we advise you to use soap format?
There are several reasons for this. The Classical Medical
Format takes a long time to fill out because it doesn't allow
the use of medical abbreviations and symbols, which are widely
used in English-speaking countries, so you might end up losing
your motivation. . On the other hand, the SOAP format is general,
so it mostly includes all the pertinent information that reflects
your decision-making process, so your classmates and/or professors,
just by looking at the specific headings, can quickly find
the information of interest without having to search through
your whole notes. It is also more reflective of your thought
processes, clinical reasoning, and decision making.
of soap notes:
These notes were taken by a fifth-year student during a ward
M/M/ mechanic c/o chest pain described as "oppressive
feeling" in the chest. Pain was associated with dizziness,
sweating and anxiety. It started unexpectedly this p.m.
PMH: MI 5 yrs ago.
FH: father died of CVA at 52.
Pt. admits heavy drinking.
O/E pt. in pain and v. anxious.
CVS: arrhythmic HS. BP 210/140. Rest of exam N.A.D.
CBC normal; fasting BS normal; CPK and transaminases ;
EKG showed atrial fibrillation and changes suggestive of AMI.
Diagnosis: MI due to clinical features, increase of enzymes
and EKG changes.
D.D. pulmonary thromboembolism, pericarditis, osteochondritis,
Immediate management: transfer to pre-coronary care unit.
IV nitroglycerine, adenosine, heparin, and morphine. Check
vital signs every three hours.
After initial symptoms are controlled, transfer pt. to ICU.
Reassessment by ICU specialists.
don't you give the SOAP format a try? We encourage you to
use in your next in-service training activity . If you or
your teacher have any questions about this format, feel free
to contact us. We will be glad to help you.
We are looking forward to receiving your comments.
R.R., English for Academic Purposes, Cambridge Unviversity
you to visit these medical sites to learn more about the SOAP