Difference between revisions of "What is a SOAP Note?"
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| Line 9: | Line 9: | ||
*Objective = Physical Exam; Results | *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 | + | *Assessment = Assessment, this is still the summary of the patient's complaints or the provider's diagnoses based on the subjective and objective information documented for the patient during the visit. |
| − | Plan | + | *Plan = Plan, this is the treatment plan and physician recommendations for treating the problem(s) the patient has been diagnosed with. |
Revision as of 22:23, 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 documented for the patient during the visit.
- Plan = Plan, this is the treatment plan and physician recommendations for treating the problem(s) the patient has been diagnosed with.