SOAP note

SOAP note

The SOAP note (an acronym for Subjective, Objective, Assessment, and Plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.

Pronunciation

/soʊp noʊt/

Etymology

The term "SOAP note" was coined in the 1960s by Dr. Lawrence Weed as part of the Problem Oriented Medical Record (POMR) system. The acronym stands for Subjective, Objective, Assessment, and Plan, which are the key components of the note.

Definition

The SOAP note is a structured method of documentation that healthcare providers use to record a patient's visit or encounter. It is divided into four sections:

• Subjective - This section includes the patient's complaints and symptoms, as well as their medical history.
• Objective - This section includes the healthcare provider's observations, such as physical examination findings and laboratory results.
• Assessment - This section includes the healthcare provider's diagnosis or impression of the patient's condition.
• Plan - This section includes the healthcare provider's proposed treatment plan, including medications, therapies, and follow-up plans.

Related Terms

• Medical record
• Clinical note
• Progress note
• Medical transcription
• Medical history
• Physical examination
• Diagnosis
• Treatment plan

See Also

• Medical documentation
• Electronic health record
• Health information management
• Medical coding
• Medical billing

External links

• Medical encyclopedia article on SOAP note
• Wikipedia's article - SOAP note

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