Chart — RT Career & Professional Practice
Clinical Documentation Formats Compared
SOAP, SOAPIER, SBAR, narrative, charting by exception — the documentation and communication formats RTs use, compared by what each section means and when each fits.
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Documentation Formats
| Format | What it stands for or its structure | Best use |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | A structured progress note |
| SOAPIER | SOAP plus Intervention, Evaluation, Revision | A detailed progress note that records response and revision |
| SBAR | Situation, Background, Assessment, Recommendation | Handoffs, escalation, and verbal or written communication |
| Narrative | A chronological free-text account | Flexible detail; events and timelines |
| Charting by exception | Documents only deviations from defined norms | Efficient routine charting when standards are clear |
How to Use This Chart
Each format serves a distinct purpose. Choosing the right one depends on whether you are writing a progress note, communicating a handoff, or charting routine care. Keep the following in mind when applying these formats in practice.
- SOAP and SOAPIER structure a progress note; SBAR structures communication such as a handoff or escalation — they serve different purposes.
- Charting by exception is efficient but only safe with well-defined normal standards (an undocumented finding is assumed normal).
- Whatever the format: document objectively and contemporaneously, and avoid the Do Not Use abbreviations.
Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Recording and communicating clinical data.
- The Joint Commission. Standards for documentation and communication. The Joint Commission.