What is a SOAP Note?
Revision as of 07:31, 23 February 2010 by Jerri.cowper (talk | contribs) (Created page with 'A SOAP note is they way providers use to document a patient's encounter. SOAP stands for '''S'''ubjective * '''O'''bjective * '''A'''ssessment * '''P'''lan This translates to …')
A SOAP note is they way providers use to document a patient's encounter.
SOAP stands for Subjective * Objective * Assessment * Plan
This translates to today's note sections as follows:
Subjective - Reason for Visit or Chief Complaint; HPI; ROS
Objective - Physical Exam; Results
Assessment - Unchanged, this is still the assessment of the patient's complaints or the diagnosis the provider assesses the patient for today.
Plan - Unchanged, this is the plan for the patient's condition or complaint.