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:
Subjective
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.
Objective
This is the physical examination portion. Vital signs, general appearance, and other findings on direct examination of the patient should be putin this section
Assessment
Diagnoses 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.
Plan
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