Difference between revisions of "What is a SOAP Note?"
Jump to navigation
Jump to search
| Line 5: | Line 5: | ||
This translates to modern 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; Active Problems; PMH; PSH; Family History; Social History; Current Meds and Allergies |
*Objective = Physical Exam; Results | *Objective = Physical Exam; Results | ||
Revision as of 22:28, 31 January 2012
SOAP is an acronym for the documentation workflow and thought process that physicians navigate through to document a patient visit.
- SOAP stands for Subjective * Objective * Assessment * Plan
This translates to modern note sections as follows:
- Subjective = Reason for Visit or Chief Complaint; HPI; ROS; Active Problems; PMH; PSH; Family History; Social History; Current Meds and Allergies
- 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.