Complete Guide to Seizure SOAP Notes for Healthcare Providers

If you've ever struggled to document a seizure event in a way that's clinically accurate and comprehensive, this guide will help you master seizure SOAP notes.

I've talked to countless nurses, EMTs, and physicians who've felt the pressure of documenting seizures quickly and thoroughly.

Whether it's an emergency room visit, a witnessed event in a clinic, or a follow-up appointment for epilepsy management, seizure documentation needs to be precise.

The details matter for treatment decisions, medication adjustments, and legal protection.

That's why I built SOAP Notes Doctor to help healthcare providers document seizures accurately without the documentation burden.

In this article, I'll break down how to write seizure SOAP notes that are clinically sound and legally defensible.

🧾 What SOAP Notes Really Are (And Where They Came From)

SOAP notes might feel like a modern invention, but they've been around for decades.

They were first introduced in the 1960s by Dr. Lawrence Weed as part of something called the Problem-Oriented Medical Record (POMR).

His goal was simple: make patient documentation clear, consistent, and useful for both providers and anyone reviewing the chart later.

And that's really the spirit of SOAP notes.

They're a structured way of telling the story of what's happening with your patient.

SOAP stands for:

• S — Subjective: What the patient or witnesses report (symptoms, sensations, warnings before the event).
• O — Objective: What you observe (vital signs, seizure characteristics, post-ictal state, lab results).
• A — Assessment: Your professional interpretation (seizure type, suspected triggers, medication compliance).
• P — Plan: What you're going to do next (medications, imaging, referrals, safety precautions).

This format keeps your documentation organized, easy to read, and easy to review which is exactly why it's the standard in neurology and emergency medicine.

You want to write in a way that communicates clearly and professionally.

How You Can Approach SOAP Notes

There's no one right way to write SOAP notes but there are better ways depending on your workflow.

Here are two approaches.

1. Traditional, Manual Notes

This is typing out every section during or immediately after the seizure event. It works well if you have time and a good memory for details. The downside is it can be rushed during emergencies, and critical details sometimes get missed when you're focused on patient care.

2. SOAP Notes Doctor

You record the event details and observations as they happen or immediately after.

The tool formats everything into a complete SOAP note and ensures you don't miss critical elements like timing, duration, and post-ictal findings.

How to Make SOAP Notes Faster

One of the biggest frustrations healthcare providers face is documenting seizures while managing active patient care.

You've just stabilized someone who had a tonic-clonic seizure, and now you need to chart everything: the timeline, the seizure characteristics, medications given, and the entire post-ictal assessment.

The temptation in that moment is either to write something quick and vague, or to delay documentation until later when your memory isn't as sharp.

Neither option is ideal.

The truth is, seizure SOAP notes don't need to take forever, but they can't afford to be incomplete especially when they might be reviewed for treatment decisions or legal purposes.

Here's the solution we built:

✅ Head to soapnotes.doctor
✅ Record your observations during or immediately after the event
✅ Save and generate comprehensive notes automatically
✅ Focus on patient care, not paperwork

With soapnotes.doctor, you can record your observations, dictate findings, or upload audio notes later, and the system automatically converts everything into a clinically complete SOAP note.

That means you get the thoroughness neurologists and insurance companies expect, but you don't have to spend 20 minutes typing after every seizure.

Maybe you observed specific seizure characteristics?

Tonic-clonic activity, eyes deviated right, postictal confusion lasting 15 minutes, etc.

Use the tailorr feature to add them. Keep your notes rough during the event. Keep them quick and soapnotes.doctor handles the formatting.

Example 1: Emergency Department Seizure

Patient: 28-year-old male
Chief Complaint: Witnessed generalized tonic-clonic seizure
Setting: Emergency Department, first-time seizure

S – Subjective:

Patient reports no memory of the event. Girlfriend witnessed seizure that occurred at home approximately 45 minutes prior to arrival. She reports patient complained of feeling "strange" and seeing "flashing lights" for about 30 seconds before losing consciousness. Patient has no history of seizures, recent head trauma, or known neurological conditions. Denies fever, recent illness, or substance use. No family history of epilepsy.

O – Objective:

Vital signs on arrival: BP 142/88 mmHg, HR 98 bpm, RR 18, Temp 98.4°F, SpO2 98% on room air. Patient initially confused and lethargic (GCS 13: E4 V4 M5), gradually improving over 20 minutes to fully alert and oriented x3. Witnessed seizure described as: sudden loss of consciousness, whole-body stiffening (tonic phase) lasting approximately 20 seconds, followed by rhythmic jerking movements of all extremities (clonic phase) lasting approximately 60 seconds. No bowel or bladder incontinence noted. Tongue bite present on right lateral surface. Neurological exam: pupils equal and reactive, no focal deficits, normal cranial nerve exam. Labs: glucose 108 mg/dL, sodium 140 mEq/L, alcohol level 0. CT head without contrast: no acute findings.

A – Assessment:

New-onset generalized tonic-clonic seizure with postictal confusion, likely unprovoked given absence of identifiable triggers and normal initial workup. Differential includes idiopathic epilepsy, though structural lesion and metabolic causes ruled out preliminarily. Patient at risk for recurrent seizures.

P – Plan:

Initiate levetiracetam 500 mg PO BID. Patient given seizure precautions and driving restrictions per state law. Outpatient neurology referral for EEG and possible MRI brain with contrast for further workup. Patient and girlfriend educated on seizure first aid, when to call 911, and importance of medication compliance. Written discharge instructions provided. Follow-up with neurology within 1 week. Return to ED if seizure recurs, lasts >5 minutes, or clusters occur.

Example 2: Epilepsy Follow-Up Visit

Patient: 34-year-old female
Chief Complaint: Breakthrough seizure despite medication compliance
Setting: Outpatient neurology clinic, established epilepsy patient

S – Subjective:

Patient reports having two breakthrough seizures in the past month, both occurring in the early morning hours (5 AM and 6 AM). Describes typical aura of rising epigastric sensation and metallic taste lasting 10-15 seconds, followed by loss of awareness. Husband reports automatisms including lip smacking and fumbling with hands, lasting approximately 45 seconds each. Patient denies any memory of these episodes. Reports normal sleep schedule, no recent stressors, and 100% medication compliance (lamotrigine 200 mg BID). No recent illness, alcohol use, or missed doses. Last seizure prior to this month was 8 months ago.

O – Objective:

Vital signs: BP 118/72 mmHg, HR 72 bpm. Alert and oriented x3, normal affect. Neurological examination unremarkable: cranial nerves II-XII intact, strength 5/5 throughout, sensation intact, coordination normal, gait steady. Recent lamotrigine level drawn last week: 6.2 mcg/mL (therapeutic range 3-14 mcg/mL). Review of seizure diary shows two focal seizures with impaired awareness in past 30 days.

A – Assessment:

Focal seizures with impaired awareness (previously controlled temporal lobe epilepsy) with recent breakthrough activity despite therapeutic medication levels. Possible causes include hormonal fluctuation, sleep disruption, or need for medication adjustment. Pattern of early morning seizures suggests possible sleep-related trigger.

P – Plan:

Increase lamotrigine to 250 mg PO BID. Repeat lamotrigine level in 2 weeks. Patient to maintain seizure diary with particular attention to sleep patterns, menstrual cycle correlation, and any potential triggers. Reinforce sleep hygiene and importance of consistent sleep schedule. RTC in 6 weeks for reassessment. If seizures persist despite medication adjustment, will consider adding second agent or video EEG monitoring. Patient verbalized understanding and agreed with plan.

Example 3: Pediatric Febrile Seizure

Patient: 18-month-old female
Chief Complaint: Seizure associated with fever
Setting: Pediatric emergency department

S – Subjective:

Per mother, patient developed fever to 102.8°F this evening and became fussy. Approximately 30 minutes after fever onset, mother noted patient became stiff, eyes rolled back, and began having rhythmic jerking of arms and legs lasting approximately 2 minutes. Mother called 911. No prior history of seizures. Patient up to date on vaccinations, no recent head trauma, no known ingestions. No family history of febrile seizures or epilepsy. No recent sick contacts though attending daycare where upper respiratory infections are circulating.

O – Objective:

Vital signs on arrival: Temp 103.2°F (rectal), HR 156 bpm, RR 28, BP 92/58 mmHg, SpO2 99% on room air. Post-ictal initially, arousable to stimulation, became fully alert within 10 minutes. Examination reveals bilateral tympanic membranes erythematous and bulging consistent with acute otitis media. No meningeal signs: negative Kernig and Brudzinski signs, neck supple. Neurological exam: moving all extremities equally, normal tone, normal fontanelle. Seizure characteristics per EMS report and mother's description consistent with generalized tonic-clonic activity, duration approximately 2 minutes, no focal features noted.

A – Assessment:

Simple febrile seizure in setting of acute otitis media. Seizure characteristics consistent with benign febrile seizure (age-appropriate, duration less than 15 minutes, generalized, single episode). No evidence of meningitis or other serious bacterial infection on examination.

P – Plan:

Acetaminophen 15 mg/kg given for fever control. Amoxicillin 40 mg/kg/day prescribed for acute otitis media. Parents educated extensively on febrile seizure management: fever control with antipyretics, seizure first aid, when to call 911 (seizure >5 minutes, multiple seizures, difficulty breathing). Reassured parents regarding low risk of epilepsy development and discussed 30% recurrence risk for future febrile illnesses. No prophylactic anticonvulsant therapy indicated. Follow-up with pediatrician in 2-3 days for recheck. Return to ED if seizure recurs, fever persists >48 hours on antibiotics, or any concerning symptoms develop.

Key Elements Every Seizure SOAP Note Should Include

When documenting seizures, certain details are non-negotiable:

Subjective Section Must Include:

• Witness description of the event (if available)
• Patient's recollection or aura symptoms
• Timing and circumstances of seizure
• Medication compliance and recent changes
• Known triggers or precipitating factors
• Previous seizure history

Objective Section Must Include:

• Vital signs (especially during/after seizure if available)
• Seizure characteristics: type, duration, body parts involved
• Level of consciousness during and after
• Post-ictal state and recovery time
• Physical examination findings
• Relevant labs, imaging, or EEG results

Assessment Section Must Include:

• Seizure classification
• Contributing factors or triggers identified
• Changes from baseline seizure pattern
• Risk assessment for recurrence

Plan Section Must Include:

• Medication adjustments or new prescriptions
• Safety precautions and driving restrictions
• Follow-up plans and referrals
• Patient/family education provided
• When to seek emergency care

Why Seizure Documentation Matters

Seizure SOAP notes aren't just paperwork they're critical for:

• Treatment optimization: Tracking patterns helps neurologists adjust medications
• Legal protection: Complete documentation protects you in liability situations
• Continuity of care: Other providers need accurate seizure descriptions
• Research and quality improvement: Good data helps improve seizure care protocols
• Disability and insurance claims: Thorough documentation supports necessary benefits

The difference between a mediocre seizure note and an excellent one often comes down to specificity and completeness.

With SOAP Notes Doctor, you don't have to choose between thorough documentation and efficient workflow.

You can have both.

Final Thoughts

Seizure documentation doesn't have to be overwhelming.

Yes, it requires attention to detail.

Yes, timing matters.

But it shouldn't take 30 minutes to write up a 2-minute seizure.

Whether you're documenting a first-time seizure in the ED, managing chronic epilepsy in clinic, or responding to a breakthrough event, the SOAP format keeps your notes organized and complete.

And if you want to make the process even faster without sacrificing quality, SOAP Notes Doctor is built exactly for this.

Record your observations. Let the tool handle the formatting. Focus on what matters most: your patient.

Ready to streamline your seizure documentation?

Head to soapnotes.doctor and see how much time you can save.