What is a SOAP Note?
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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.