The term SOAP is an acronym representing a standardized method of documentation used by healthcare providers across various medical settings. This structured format ensures that all patient encounters are recorded comprehensively and logically. The primary function of the SOAP note is to standardize communication among members of a healthcare team, providing a clear, organized record of a patient’s status and care plan.
The acronym stands for Subjective (S), Objective (O), Assessment (A), and Plan (P). This represents the order in which a clinician gathers information, analyzes it, and determines the next steps for a patient’s care. Following this consistent structure allows any provider to quickly understand the patient’s situation and progress, promoting continuity of care and reducing the likelihood of errors in treatment.
Gathering the Clinical Data (Subjective and Objective)
The first two components, Subjective and Objective, are dedicated to collecting all relevant clinical data from and about the patient. The Subjective section captures the patient’s personal experience of their illness, which cannot be directly measured or verified by the clinician. This includes the patient’s chief complaint, the reason they sought medical attention, often recorded in their own words.
Documentation here details the history of the present illness, organizing information such as the onset, location, duration, and severity of symptoms. For example, a patient’s statement, “I have had a dull ache in my lower back for three days,” belongs in the Subjective section. This part also includes relevant past medical history, family history, and social history, providing context for the current presentation.
The Objective section contrasts with the Subjective by containing only measurable, verifiable, and unbiased facts observed by the healthcare provider. This section documents clinical signs, which are findings that can be quantified or confirmed by an external observer. Objective data starts with vital signs, such as blood pressure, heart rate, respiratory rate, and temperature, offering a baseline snapshot of the patient’s physiological status.
It also includes findings from the physical examination, such as observing a patient’s gait, palpating an area of tenderness, or auscultating lung sounds. Furthermore, all diagnostic test results, including laboratory data (like a complete blood count) and imaging reports (from an X-ray or MRI), are documented here. The distinction between the subjective complaint of “stomach pain” and the objective sign of “abdominal tenderness to palpation” is a fundamental separation.
Interpreting the Findings (Assessment)
The Assessment component is where the clinician synthesizes the Subjective and Objective data to arrive at a logical conclusion about the patient’s health status. This section is the professional’s analysis and clinical judgment, not a restatement of the findings. It demonstrates the provider’s thought process by linking the patient’s reported symptoms with the measurable signs.
The primary element here is the working diagnosis, or a list of diagnoses, which explains the patient’s problem. Clinicians often construct a differential diagnosis—a ranked list of possible conditions from most to least likely. The rationale for selecting the leading diagnosis is documented by referencing specific positive and negative findings from the S and O sections that support or rule out a possibility.
For patients with chronic conditions, the Assessment also includes a statement on the current status of the problem, noting if the condition is stable, improving, or worsening since the last encounter. This section acts as a bridge, demonstrating how the collected evidence leads directly to the proposed management strategy. A well-written Assessment shows the clinician’s ability to interpret information and justify their conclusion, supporting the medical necessity of the subsequent interventions.
Defining the Course of Action (Plan)
The final section, the Plan, outlines the specific actions that will be taken to address the diagnoses made in the Assessment. This component is entirely forward-looking and focuses on the management strategy for each identified problem. The Plan is organized into three distinct areas of action.
Diagnostic
This area details any further testing needed to confirm a diagnosis, rule out a differential, or monitor a condition. This might include ordering blood work, scheduling a follow-up imaging study, or referring the patient to a specialist. These steps are designed to resolve any remaining ambiguities in the Assessment.
Therapeutic
This includes all interventions intended to treat the patient’s condition. This covers writing prescriptions for medications, ordering procedures, referring the patient to other providers (like surgeons or physical therapists), and specific lifestyle modifications recommended.
Patient Education and Follow-up
This details instructions given to the patient, such as signs to watch for, when to return for a re-evaluation, or scheduling the next appointment.