Difference between revisions of "What is a SOAP Note?"
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*Subjective = Reason for Visit or Chief Complaint; HPI; ROS | *Subjective = Reason for Visit or Chief Complaint; HPI; ROS | ||
| − | Objective | + | *Objective = Physical Exam; Results |
| − | Assessment | + | *Assessment = Assessment, this is still the summary of the patient's complaints or the provider's diagnoses based on the subjective and objective information gathered for the patient during the visit. |
Plan - Unchanged, this is the plan for the patient's condition or complaint. | Plan - Unchanged, this is the plan for the patient's condition or complaint. | ||
Revision as of 22:21, 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 = Assessment, this is still the summary of the patient's complaints or the provider's diagnoses based on the subjective and objective information gathered for the patient during the visit.
Plan - Unchanged, this is the plan for the patient's condition or complaint.