Difference between revisions of "What is a SOAP Note?"
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| − | SOAP is an acronym for the workflow | + | SOAP is an acronym for the documentation workflow and thought process that physicians navigate through to document a patient visit. |
*SOAP stands for '''S'''ubjective * '''O'''bjective * '''A'''ssessment * '''P'''lan | *SOAP stands for '''S'''ubjective * '''O'''bjective * '''A'''ssessment * '''P'''lan | ||
Revision as of 22:27, 31 January 2012
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
- 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.