The Right Way to Write SOAP Notes for Epilepsy

SOAP Notes for Epilepsy

If you've ever sat down to write SOAP notes after seeing an epilepsy patient, you know it's not always straightforward.

Do I include every seizure detail? How do I keep it concise but still clear?

I built soapnotes.doctor to take away that stress, but I also believe understanding the framework is key.

In this guide, I'll walk you through SOAP notes for epilepsy. We'll break it down so you can document faster, clearer, and with confidence.

What Are SOAP Notes?

SOAP notes are nothing new.

They've been around since Dr. Lawrence Weed introduced them in the 1960s as part of the Problem-Oriented Medical Record. But despite all the changes in healthcare tech, this framework has stood the test of time.

Here's why: SOAP notes make documentation simple.

They break things down into four buckets—Subjective, Objective, Assessment, and Plan.

Together, these sections tell the patient's story in a clear, structured way that any clinician can pick up and understand.

How to Approach SOAP Notes for Epilepsy

Writing SOAP Notes for epilepsy can be challenging because much of the information you work with comes from what the patient or caregiver reports, combined with your interpretation of clinical data. Not ideal.

Here's how I recommend approaching it.

S – Subjective: Listening First, Always

The subjective section is the most important part of any SOAP note.

Seizures are not something we can always witness directly; most of the time, we rely on what patients, family members, or caregivers report.

This means accuracy hinges on attentive listening and asking the right questions.

It's not enough to simply note "patient reports seizure."

You want to dig deeper: when did the seizure occur, how long did it last, what did it look like, and how did the patient feel before and after?

When I approach this section, I treat it almost like storytelling.

Allow the patient or caregiver to describe the event in their own words, and then structuring it clearly in my note.

Documenting aura experiences (strange smells, visual changes, or unusual feelings before the seizure) is especially important, since these can help track seizure type and triggers.

Post-ictal symptoms like confusion, fatigue, or headache should also be recorded. In my opinion, the more specific the subjective detail, the more valuable the note becomes for long-term epilepsy management.

Quick Tip: Use SoapNotes.doctor to record these sessions. It'll do the work of writing the SOAP notes tailored to the specific case. All you have to do is iterate on what you've already gotten.

O – Objective: Precision in What You Measure

The objective section for epilepsy should never be empty, even when a seizure wasn't directly observed during the clinical encounter.

Too often, I see notes where this part is skipped or left vague, which reduces the clinical usefulness of the SOAP note.

At minimum, document vitals, neurological exam findings, and any observed physical signs that may be related to recent seizures (e.g., tongue biting, bruises, or injuries from falls).

These small but important details help paint a fuller picture.

Beyond the bedside, objective data often comes from diagnostic tools: EEG results, lab work to check medication levels, or imaging reports if available.

Even medication adherence (pill counts, pharmacy refill records, or patient reports backed with documentation) fits into this section.

I would argue that in epilepsy SOAP notes, this section benefits from being as data-heavy as possible, because subjective reports can vary, but numbers, lab results, and exam findings add weight and clarity.

Quick Tip: You can add these using the tailorr feature in soapnotes.doctor to get a well generated objective session.

A – Assessment: Clinical Judgement Matters Here

At this point, you make clinical reasoning.

You connect the dots between what was observed and the subjective section.

For epilepsy, that might mean identifying whether the patient's seizures are controlled, poorly controlled, or worsening.

If the patient is experiencing breakthrough seizures despite adherence, your assessment should highlight that.

If you suspect triggers like sleep deprivation, missed doses, or stress, this is the space to acknowledge it.

I tend to take a clear, opinionated stance here.

For example, if a patient's seizure diary is inconsistent but the caregiver confirms frequent events, I'll state plainly in the assessment that seizures are likely underreported, and treatment adjustments should not wait for "perfect" documentation.

This may seem bold, but in epilepsy care, under-treatment due to cautious documentation can do more harm than good.

The assessment should always answer the unspoken question: "What is my professional judgment of where the patient stands today?"

Quick tip: With proper context added in the tailorr feature, you should easily get this properly generated on SoapNotes.doctor

P – Plan: Making It Actionable

People should stop writing generic plans.

And if you can't help it, this is one reason we built SoapNotes.doctor. Your plan section should never be generic.

Saying "continue current management" without context is underreporting.

Instead, spell out the concrete steps: adjusting medication dosages, ordering an EEG, scheduling follow-up labs, or setting a specific timeframe for reassessment.

For epilepsy, patient education is also part of the plan addressing safety concerns like driving restrictions, seizure first aid, or avoiding known triggers.

In my approach, I also document caregiver instructions here. Epilepsy often involves more than the patient alone, and leaving out caregiver education from the plan weakens the continuity of care.

For example, I'll note: "Educated caregiver on proper rescue medication administration and when to seek emergency help."

That way, anyone reviewing the note later sees the proactive measures taken. In epilepsy management, the plan is where you set the tone for ongoing stability, safety, and trust.

Opinionated Take: Don't Be Robotic With SOAP Notes

One mistake I see often is clinicians treating SOAP notes like robotic checklists.

Yes, the structure is important, but epilepsy is unpredictable and deeply personal.

A seizure for one patient may look completely different for another. If you only stick to rigid templates, you risk missing the nuances that make a big difference in care.

That's why I recommend approaching SOAP notes for epilepsy as dynamic narratives inside a structured box.

Use the SOAP framework to keep yourself organized, but don't be afraid to expand details where necessary especially in the subjective and assessment sections.

In fact, I believe the best SOAP notes read like both a medical record and a practical handoff: something another clinician could pick up tomorrow and instantly know how to continue care.

Example SOAP Note for Epilepsy

S - Subjective

Patient reports three seizures in the past two weeks, each lasting about 1–2 minutes. Aura described as flashing lights and metallic taste. Caregiver states patient appeared confused for 10–15 minutes afterward, with headache and fatigue. Patient denies missed doses but admits poor sleep.

O - Objective

Vitals stable. Neurological exam unremarkable. Tongue laceration noted, consistent with recent tonic-clonic seizure. Last carbamazepine level 5 mcg/mL (low therapeutic range). EEG from previous month showed left temporal discharges.

A - Assessment

Poor seizure control with breakthrough tonic-clonic seizures. Possible contributing factors: poor sleep hygiene, subtherapeutic carbamazepine level. High risk for further breakthrough events.

P - Plan

Increase carbamazepine dosage from 200 mg BID to 300 mg BID. Order repeat carbamazepine level in 2 weeks. Educate patient on importance of sleep hygiene. Caregiver instructed on seizure first aid and to administer rescue medication if seizure exceeds 5 minutes. Follow-up in 4 weeks.

---

This article was brought to you by SOAPNotes.doctor