Difference between revisions of "What is a SOAP Note?"
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This translates to modern note sections as follows: | This translates to modern note sections as follows: | ||
− | *Subjective | + | *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. |
− | *Objective | + | *The Objective component includes 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. | *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. | *Plan = Plan, this is the treatment plan and physician recommendations for treating the problem(s) the patient has been diagnosed with. |
Revision as of 22:30, 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:
- 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 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.