What is a SOAP Note?
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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.