Emergency Medicine: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Emergency medicine documentation requires balancing thoroughness with efficiency in high-acuity, time-sensitive environments. ED SOAP notes must capture the rapid assessment process, medical decision-making complexity, and disposition planning that characterize emergency care. This guide covers documentation best practices for the full spectrum of ED encounters.

Unique Aspects of Emergency Medicine Documentation

ED documentation differs from outpatient notes in several key ways:

1. Time-Critical: Documentation must support rapid decision-making
2. Acuity-Based: Triage level influences documentation depth
3. Medical Decision-Making (MDM): Critical for E/M coding and liability
4. Disposition Focus: Admission, discharge, or transfer decisions must be clearly justified
5. Handoff Documentation: Critical for shift changes and care transitions
6. Medico-Legal Importance: ED notes frequently reviewed for liability cases

Subjective Section (S)

The Subjective section in emergency medicine captures the presenting complaint and must efficiently gather critical information to guide workup and treatment.

Subjective Section (S) Components

1. Chief Complaint:

   • Brief statement with duration
   • Triage acuity level
   • Mode of arrival (ambulance, walk-in, transfer)
   • Example: "Chest pain x 2 hours, arrived by EMS. Triage: ESI Level 2"

2. History of Present Illness:

   • OPQRST format for pain/symptoms (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing)
   • Associated symptoms
   • Pertinent negatives critical for differential
   • Example: "Sudden onset substernal chest pressure while at rest, 8/10 severity, radiating to left arm, associated with diaphoresis and nausea. Denies shortness of breath, palpitations, or recent illness."

3. Pertinent Review of Systems:

   • Focused on ruling in/out critical diagnoses
   • Document both positives and important negatives
   • Example: "Denies syncope, fever, cough, leg swelling, or recent immobilization."

4. Past Medical History:

   • Focus on conditions relevant to chief complaint
   • Cardiac risk factors for chest pain, bleeding risk for trauma, etc.
   • Example: "HTN, HLD, DM2, prior MI 2019 with stent to LAD"

5. Medications and Allergies:

   • Current medications, especially anticoagulants, antiplatelets, cardiac meds
   • Drug allergies with reaction type
   • Example: "ASA 81mg, metoprolol 50mg BID, atorvastatin 40mg. NKDA"

6. Social History:

   • Pertinent to presentation (smoking for chest pain, IVDU for fever, etc.)
   • Living situation for disposition planning
   • Example: "Active smoker 1 PPD x 30 years. Lives alone, independent with ADLs."

Example Subjective Section for Emergency Medicine

Objective Section (O)

The ED Objective section documents triage data, physical examination, and all diagnostic results critical for clinical decision-making.

Objective Section (O) Components

1. Triage Vital Signs:

   • Initial and repeat vital signs
   • Document timing of each set
   • Example: "Initial (14:32): BP 158/94, HR 92, RR 18, SpO2 96% RA, Temp 98.4°F"

2. Physical Examination:

   • Focused exam based on chief complaint
   • Document positive and pertinent negative findings
   • General appearance is critical (toxic vs. non-toxic appearing)

3. Diagnostic Results:

   • ECG interpretation
   • Laboratory values with abnormals highlighted
   • Imaging results
   • Document timing of critical results

4. Procedures:

   • Document any procedures performed with findings
   • Example: "Bedside echo: No pericardial effusion, grossly normal LV function"

5. Reassessments:

   • Document clinical trajectory
   • Response to interventions
   • Example: "Post-NTG: Pain improved to 2/10, BP 138/82"

Example Objective Section for Emergency Medicine

Assessment Section (A)

The Assessment must clearly document the working diagnosis, medical decision-making complexity, and risk stratification.

Assessment Section (A) Components

1. Primary Diagnosis:

   • Most likely diagnosis with ICD-10
   • Example: "STEMI, anterior wall (I21.09)"

2. Clinical Reasoning:

   • Evidence supporting diagnosis
   • Critical differentials considered
   • Risk stratification

3. Medical Decision-Making (MDM):

   • Number and complexity of problems
   • Data reviewed and ordered
   • Risk of complications, morbidity, or mortality

4. Risk Assessment:

   • For chest pain: HEART score, TIMI score
   • For PE: Wells score, PERC
   • Document scores used

Example Assessment Section for Emergency Medicine

Plan Section (P)

The ED Plan must document all interventions, consultations, and disposition with clear justification.

Plan Section (P) Components

1. Immediate Interventions:

   • Time-sensitive treatments already initiated
   • Rationale for interventions

2. Consultations:

   • Specialists contacted
   • Recommendations received
   • Example: "Cardiology consulted - Dr. Smith accepting for emergent cath"

3. Disposition:

   • Admission (level of care), discharge, or transfer
   • Clear justification for disposition
   • Example: "Admit to CCU for post-PCI monitoring"

4. Discharge Instructions (if applicable):

   • Clear return precautions
   • Follow-up arranged
   • Prescriptions with instructions

Example Plan Section for Emergency Medicine

ED-Specific Documentation Considerations

Critical Results Documentation

Procedures Documentation

AI-Assisted Documentation for Emergency Medicine

AI scribes and ambient clinical intelligence are being adopted in emergency departments to address documentation burden. According to AMA research, 66% of healthcare providers now use AI tools.

ED-Specific AI Considerations

What AI captures well:

• History of present illness from patient conversation
• Review of systems
• Procedure discussions and consent
• Discharge instructions given

What requires careful review:

• Vital sign accuracy and timing
• Medication doses and timing
• Critical value documentation
• Time stamps for quality metrics (door-to-ECG, door-to-balloon)
• Medical decision-making documentation
• Consultant recommendations

Tips for ED AI Documentation

1. Verbalize times: "The time is now 14:45 and I'm reviewing the troponin result"
2. State MDM explicitly: "This is a high-complexity decision due to..."
3. Dictate critical findings: "ECG shows 2 millimeter ST elevation in V2 through V4"
4. Document reassessments: "Reassessing patient now - pain improved to 2 out of 10"

For more details, see our AI-Assisted Documentation Guide.

Telehealth in Emergency Medicine

While emergency medicine is primarily in-person, telehealth has roles in:

• Tele-triage for lower acuity complaints
• Specialist consultation (tele-stroke, tele-psychiatry)
• Follow-up for discharged patients
• Transfer center coordination

Per CMS guidelines, telehealth documentation requirements apply when used.

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Emergency Medicine SOAP Note Template

Related Resources

• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Cardiology SOAP Notes