What is a SOAP Note?

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:

• The Subjective component includes the Reason for Visit or Chief Complaint; History of Present Illness; Review of Systems; Active Problems; Past Medical History; Past Surgical History; Family History; Social History; Current Meds and Allergies note sections.

• The Objective component includes the Vital Signs; Physical Exam and Results/Data note sections.

• Assessment is typically just the Assessment note section. This may include the summary of the patient's complaints as well as the provider's diagnoses based on the subjective and objective information documented for the patient during the visit. Diagonoses are listed in order of most likely to least likely based on the information available at the time of assessment.

• Plan is typically just the Plan note section. This is the treatment plan and physician recommendations for treating the problem(s) the patient has been diagnosed with. This includes lab orders, radiology orders, referrals, procedure orders & medication orders. Also here is where you'd see specific patient instructions or patient education topics on treatment protocols.