NOTE SOAP
Organize the query into subjective, objective, assessment, and plan
When clinical information is scattered, it becomes difficult to pick up the case again at the next visit. A SOAP note allows you to organize what the patient reports, what is observed, the professional assessment, and the next steps.
CLINICAL STRUCTURE
A SOAP note should clearly state: * **Subjective:** What the patient reports (their symptoms, feelings, and concerns). * **Objective:** What the clinician observes and measures (vital signs, physical exam findings, test results). * **Assessment:** The clinician's diagnosis or impression of the patient's condition. * **Plan:** The course of action for treatment, further testing, or follow-up.
The SOAP structure helps separate the patient's history from findings and the plan. The exact content changes according to the practitioner's care and judgment.
Subjective
Reason for consultation, symptoms, reported evolution, current treatments, and history that influences care.
Target
Vital signs, examination, results, studies, and findings that were observed or reviewed during the consultation.
Analysis and Plan
Clinical impression, prioritized problems, indications, studies, references, and agreed-upon follow-up.
SOAP Note
- Subjective Reason for consultation and evolution of the problem as reported.
- Objective available exploration data, measurements, and studies.
- Analysis: Assessment of active problems and their clinical priority.
- Plan Indications, testing, follow-up, and signs requiring re-evaluation.
Information clarifying the following decision
This sample summarizes the type of information that a SOAP note can make available after care. It does not substitute professional judgment or reproduce.
Before saving or signing, the professional reviews the draft to ensure it corresponds to the actual care provided, corrects omissions, and decides what information should remain in the final note.
CLINICAL DOCUMENTATION WITH AI
From a conversation to a reviewable SOAP draft
Itaca can start with an in-person consultation, a video call, a clinical document, or a quick note. It organizes the available context into a SOAP draft so you can review it, make corrections, and decide what to save or sign.
- Less time transcribing after each visit.
- Ordered information for making the following decision.
- Professional review before saving or signing.
Learn how it works Clinical documentation with AI In Ithaca.
FOR CLINICS AND MEDICAL EQUIPMENT
Continue using the SOAP note format that your team is already familiar with
If your clinic already uses its own format, you can upload an example. Itaca converts it into a reusable template for future care, without asking the team to write prompts or abandon the order they already recognize.
Administrators retain visibility into usage and access, while each professional reviews and approves their own documentation. Learn about the Clinic software from Ithaca.
FREQUENTLY ASKED QUESTIONS
Questions about SOAP notes
What does SOAP stand for in a clinical note?
SOAP organizes the note into subjective, objective, assessment, and plan. It's a way to order clinical information; the professional decides which data is relevant for each encounter.
Is the grade saved automatically as final?
No. Itaca prepares a revisable draft. The professional confirms the content, corrects what is necessary, and decides when to save or sign the final note.
Can I use the format my clinic already uses?
Yes. You can upload an example of your current format, and Itaca will convert it into a reusable template for future patient visits.
Does Itaca use clinical data to train models?
No. Clinical data belongs to the user and their organization; it is not used to train models or sold to third parties.
Turn every patient visit into a SOAP note that's ready for review
Start with the workflow you already use and let Ithaca organize the draft. You have the final say on what is kept, communicated, or signed.