Understanding SOAP Notes in Medical Coding
In medical documentation and medical coding, SOAP notes are one of the most widely used formats for recording patient encounters. SOAP stands for Subjective, Objective, Assessment, and Plan. This structured approach ensures providers document consistently while giving coders the information they need to assign accurate diagnosis and procedure codes.
What Does SOAP Stand For?
S – Subjective
This section captures the patient’s perspective:
- Chief complaint (reason for visit)
- Symptoms described in the patient’s own words
- Medical history, family history, lifestyle, and risk factors
Example: “Patient reports shortness of breath and fatigue for the past three days.”
O – Objective
This part includes clinical observations and measurable data:
- Vital signs (blood pressure, temperature, pulse, oxygen saturation)
- Physical examination findings
- Laboratory results and imaging studies
Example: BP 160/95, chest X-ray reveals mild infiltrates.
A – Assessment
This is the provider’s clinical judgment or diagnosis:
- Differential diagnoses considered
- Primary condition identified
- Status of chronic conditions
Example: “Likely community-acquired pneumonia. Rule out cardiac involvement.”
P – Plan
This details the next steps for treatment and follow-up:
- Prescriptions and therapy
- Procedures ordered
- Referrals to specialists
- Patient education and instructions
Example: “Start oral antibiotics, order CBC, follow-up in 5 days.”
Why SOAP Notes Matter for Medical Coding
Accurate and complete SOAP documentation is essential for coders because:
- Supports Medical Necessity – Coders need both subjective symptoms and objective findings to justify diagnoses.
- Links Diagnosis to Treatment – The assessment and plan show why a procedure or service was performed.
- Improves Coding Accuracy – Detailed documentation reduces the risk of upcoding, downcoding, or denials.
- Enhances Compliance – SOAP notes meet payer, CMS, and legal requirements for proper documentation.
Example: SOAP Note to ICD-10-CM and CPT Code
SOAP Entry:
- S: Patient complains of cough, fever, and chest pain.
- O: Temp 101.8°F, crackles in left lung, chest X-ray confirms pneumonia.
- A: Diagnosis – J18.9 Pneumonia, unspecified organism.
- P: Prescribed azithromycin, ordered follow-up in 7 days.
Coding Result:
- ICD-10-CM: J18.9 – Pneumonia, unspecified organism
- CPT: 99214 – Office or other outpatient visit, established patient, moderate medical decision making. Pneumonia with fever is an acute illness with systemic symptoms (moderate problem), and prescribing azithromycin is prescription drug management (moderate risk), so two of three MDM elements reach moderate.
Key Takeaway
SOAP notes provide the foundation for accurate medical coding. By following the Subjective, Objective, Assessment, and Plan structure, providers ensure their notes clearly communicate the patient’s condition and medical decision-making. Coders rely on this structure to select the correct ICD-10-CM, CPT, and HCPCS codes, ensuring claims are accurate, compliant, and supported by strong documentation.
Where Coders Find Each Code in a SOAP Note
| Section | What the coder pulls from it |
| Subjective | Chief complaint, history and symptoms; signs and symptoms are coded only when no definitive diagnosis is made |
| Objective | Exam findings, test results and data reviewed, which support MDM data and clinical validation |
| Assessment | The diagnoses to code with ICD-10-CM, and the number and complexity of problems for MDM |
| Plan | Procedures, prescriptions, orders and referrals, which drive CPT and HCPCS codes and MDM risk |
Common SOAP Note Coding Mistakes
- Coding symptoms from the Subjective section when the Assessment gives a confirmed diagnosis
- Coding “rule out” or “probable” diagnoses in the outpatient setting; code the symptoms instead
- Missing chronic conditions the provider addressed in the Plan
- Choosing an E/M level from the length of the note instead of MDM or total time
Frequently Asked Questions About SOAP Notes
What does SOAP stand for?
Subjective, Objective, Assessment and Plan.
Which part of a SOAP note do coders use most?
The Assessment and Plan, because they hold the provider’s diagnoses and management decisions. The Subjective and Objective sections support them.
Can I code from the Subjective section?
Only when the provider has not documented a definitive diagnosis. Then signs and symptoms may be coded.
Do SOAP notes determine the E/M level?
The format does not set the level. The E/M level is based on medical decision making or total time documented. See our E/M coding guidelines 2026.