Difference between revisions of "What is a SOAP Note?"
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This translates to modern note sections as follows: | This translates to modern note sections as follows: | ||
| − | Subjective | + | *Subjective = Reason for Visit or Chief Complaint; HPI; ROS |
Objective - Physical Exam; Results | Objective - Physical Exam; Results | ||
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.