Every clinical note answers the same underlying questions: what did the patient tell you, what did you find, what do you think is going on, and what are you going to do about it. How you organize those answers on the page is what we call a note format. Two formats dominate the conversation, and they are often confused for one another: SOAP and the POMR. They are not competitors so much as two layers of the same idea, and understanding the relationship between them makes you a clearer, faster documenter.
This is also a practical question in 2025, because more notes are being drafted by software than ever before. When an AI scribe is generating your first draft, a predictable structure stops being a stylistic preference and becomes the thing that keeps the draft safe to read and quick to edit. We will come back to that, but first the definitions.
What SOAP actually means
SOAP is an acronym for the four sections of a single encounter note. It is the workhorse of progress notes worldwide because it maps cleanly onto how a clinical visit actually flows.
- Subjective — what the patient reports: the chief complaint, history of present illness, symptoms, relevant past history, and anything else you learn by listening rather than measuring.
- Objective — what you observe and measure: vital signs, physical exam findings, lab results, imaging, and other reproducible data.
- Assessment — your clinical reasoning: the working diagnosis or differential, and how the subjective and objective pieces fit together.
- Plan — what happens next: investigations ordered, treatment started, referrals, patient education, and follow-up.
SOAP's strength is discipline. By forcing you to separate what was said from what was found from what you concluded, it discourages the common error of letting an assumption ride along as if it were a fact. Its main limitation is that a single SOAP note describes one encounter for one set of problems. In a patient with several active conditions, a long unstructured Assessment can blur which reasoning belongs to which problem.
What the POMR adds
The Problem-Oriented Medical Record was introduced by Dr. Lawrence Weed in the late 1960s as a way to organize the entire chart, not just one note, around the patient's problems. A POMR has four classic components: a defined database (history, exam, baseline results), a numbered problem list that serves as the chart's table of contents, an initial plan for each problem, and ongoing progress notes.
The key insight is the problem list. Instead of a chart organized strictly by date, the POMR is organized by problem — hypertension is problem 1, type 2 diabetes is problem 2, and so on — so anyone opening the record can see at a glance what is being managed and follow each thread over time. This is why the POMR shines in primary care, chronic disease management, and any setting where a patient carries multiple active conditions across many visits.
The relationship in one sentence
SOAP is the format of an individual note; the POMR is the format of the whole record — and the progress notes inside a POMR are usually written in SOAP, one mini-SOAP per active problem. You are not choosing between them so much as deciding whether your single notes also sit inside a problem-oriented chart.
Choosing between them in practice
For a discrete, single-issue encounter — an acute sore throat, a minor injury, a focused follow-up — a standalone SOAP note is clean and sufficient. Adopting the full POMR machinery for a one-problem visit is overhead you do not need. The POMR earns its keep when continuity and multimorbidity are in play: when several problems coexist, when many clinicians share the chart, or when you need to track each condition's trajectory over months. The honest trade-off is effort. A well-maintained problem list takes ongoing curation; let it go stale and it misleads instead of guiding.
Why structure matters more when AI drafts the note
When you write a note by hand, you hold the structure in your head and the format is mostly a discipline aid. When software produces the first draft from a recording, the structure becomes load-bearing. A consistent template tells you exactly where to look to verify each claim, makes omissions visible, and lets you scan and correct in seconds rather than re-reading prose. If you want the mechanics of how transcription and drafting actually work end to end, we cover that in how AI medical scribes work.
This is the reasoning behind how the AI medical scribe in Shifaa AI structures its output. It transcribes the visit with OpenAI Whisper, then drafts a SOAP-formatted note with Anthropic Claude — and, importantly, it fills empty fields only, never overwriting what the clinician has already written. The format is deliberate: SOAP gives the doctor a fixed, predictable shape to review, so the draft is a starting point to check and sign rather than a wall of text to untangle. If your practice runs a problem-oriented chart, those SOAP drafts slot in as the progress notes under each problem, exactly as Weed intended.
Whichever format you adopt, the goal is the same: a record that a colleague — or your future self — can read quickly and trust. SOAP gives each note its shape, the POMR gives the chart its spine, and a consistent structure is what keeps both honest when part of the drafting is automated.