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 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.