The SOAP note is used in the health care profession to document patient visits. The note covers in general categories most information that needs to be gathered to document medical visits. The letters stand for the following:
The subjective portion of the notes contains the information you receive from the patient. It may include
In this section you try to document
everything possible that might shed light on a patient's condition.
This is the physical examination portion. Vital signs, general appearance, and other findings on direct examination of the patient should be putin this section
and any speculation
are placed in this section. Sometimes, a diagnosis hasn't been made, and the section consists of a list of differential diagnoses
for the symptoms the patient has had.
Simply put, what does the medical professional intend to do about the problem
or problems listed in the assessment section? Here's where that is documented.
See also: SNOCAMP note