Difference between revisions of "What is a SOAP Note?"

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*SOAP stands for '''S'''ubjective * '''O'''bjective * '''A'''ssessment * '''P'''lan
 
*SOAP stands for '''S'''ubjective * '''O'''bjective * '''A'''ssessment * '''P'''lan
  
This translates to today's note sections as follows:
+
This translates to modern note sections as follows:
  
 
Subjective - Reason for Visit or Chief Complaint; HPI; ROS
 
Subjective - Reason for Visit or Chief Complaint; HPI; ROS

Revision as of 22:19, 31 January 2012

A SOAP note is they way providers use to document a patient's encounter.

  • SOAP stands for Subjective * Objective * Assessment * Plan

This translates to modern 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.