The SOAP method is a widely recognized, systematic approach to organizing patient medical records and structuring clinical documentation across various healthcare disciplines. This format provides a standardized narrative for tracking a patient’s health status over time, ensuring a logical flow of information from the initial encounter to the subsequent course of action. Its adoption, often integrated into electronic health records (EHRs), promotes clarity and consistency in documentation. The goal of this structure is to facilitate clear communication among all healthcare providers, reducing the potential for error and supporting collaborative decision-making.
Subjective Data
The first component captures information provided directly by the patient or a family member acting as a proxy. This data is based entirely on the patient’s perception and self-report, meaning it cannot be independently measured or verified by the clinician. The section typically begins with the Chief Complaint (CC), the primary reason the patient sought care, often recorded using the patient’s own words.
The Subjective section also includes the History of Present Illness (HPI), a detailed narrative describing the symptoms, their onset, severity, location, and factors that make them better or worse. Relevant past medical history, current medications, allergies, and social history that may impact the current issue are also recorded here. Direct quotes are frequently used to preserve the patient’s exact description, such as reporting a pain level of “8 out of 10.”
Objective Findings
The second component documents all measurable, observable, and verifiable data collected by the healthcare provider during the encounter. This information is factual and reproducible, serving as the foundation for the clinical evaluation. The Objective section includes vital signs, such as temperature, blood pressure, heart rate, and oxygen saturation, which offer baseline physiological measurements.
Results from the physical examination are recorded, including general appearance, specific findings upon inspection, palpation, and auscultation, or observations like range of motion in a joint. Diagnostic data is also integrated into this section, covering laboratory results, imaging reports (like X-rays or CT scans), and other measurable test scores. The Objective section focuses on what the provider observes and measures.
Assessment
The Assessment section represents the clinician’s synthesis and interpretation of the preceding Subjective and Objective data. Here, the provider forms a clinical judgment about the patient’s condition. This section typically contains the working diagnosis or a prioritized list of possible diagnoses, known as differential diagnoses, ranked from most to least likely.
The clinician must articulate the reasoning that links the reported symptoms and the measured findings to the stated diagnosis. For example, Objective findings like a fever and a specific lung sound would justify a diagnosis of pneumonia in the Assessment. If a definitive diagnosis cannot be immediately established, the Assessment articulates the clinical impression or describes the stability and severity of the current problem. This section translates the raw data into a clinically meaningful conclusion, setting the stage for the subsequent course of action. It also documents the patient’s progress or regression since the last visit.
Plan
The final component outlines the specific course of action determined by the provider based on the Assessment’s conclusions. The Plan must directly address each diagnosis or problem listed, ensuring every identified issue has a corresponding proposed intervention. This section is structured to be specific, measurable, and easily executable by the patient or other members of the healthcare team.
The Plan is typically categorized into diagnostic steps, therapeutic interventions, and patient education. Diagnostic plans specify further testing, such as ordering blood work, specialized imaging, or referrals to confirm or rule out a diagnosis. Therapeutic plans detail treatments like new medications, changes to existing prescriptions, physical therapy referrals, or other procedures. The Plan also includes instructions for patient education and defines the follow-up schedule.