SOAP

SOAP

SOAP (Subjective, Objective, Assessment, Plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the ADIME note. The SOAP note is a way for healthcare professionals to document a patient's care in a structured and easy-to-read format. This method ensures that comprehensive information is collected and improves communication among healthcare providers.

Subjective

The Subjective section of a SOAP note includes information that the patient reports. This can include symptoms, feelings, and concerns. It is the patient's description of their current condition, often including details such as pain intensity, the location of pain, and any activities or circumstances that make the condition better or worse. This section is crucial as it provides insight into the patient's perspective and helps guide the healthcare provider's assessment.

Objective

The Objective section records information that the healthcare provider observes or measures directly. This can include physical examination findings, vital signs (such as blood pressure, temperature, heart rate, and respiratory rate), laboratory results, and imaging studies. The objective data are facts and figures that provide evidence to support the diagnosis and guide treatment.

Assessment

The Assessment section is where the healthcare provider synthesizes the subjective and objective information to make a clinical judgment. This may involve diagnosing the patient's condition, identifying a list of possible conditions (differential diagnoses), or noting changes in the patient's status. The assessment is a critical step as it forms the basis for the treatment plan.

Plan

The Plan section outlines the steps that the healthcare provider will take to treat the patient's condition. This can include ordering additional tests, referring the patient to a specialist, prescribing medication, and suggesting lifestyle modifications. The plan is tailored to the individual patient and is based on the information gathered in the subjective and objective sections, as well as the assessment.