SOAP note

A SOAP note is a documentation method used by healthcare providers to record a patient's encounter. It stands for Subjective, Objective, Assessment, and Plan, and provides a structured way to organize and present patient information. The SOAP format helps ensure consistent and comprehensive record-keeping, facilitating communication between healthcare professionals and contributing to effective patient care.

• Subjective: This section contains information reported by the patient or their caregiver. It includes the patient's chief complaint (the primary reason for seeking care), history of present illness (HPI, a detailed account of the current problem), past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS). The subjective section captures the patient's perspective and experiences.

• Objective: This section documents measurable and observable data gathered during the examination. It includes vital signs (temperature, heart rate, blood pressure, respiratory rate), physical examination findings, and results from diagnostic tests such as laboratory studies, imaging reports (X-rays, CT scans, MRIs), and other relevant assessments.

• Assessment: This section represents the healthcare provider's professional interpretation of the subjective and objective data. It includes the diagnosis or differential diagnoses, a summary of the patient's condition, and an explanation of the reasoning behind the diagnoses. It may also include a problem list identifying the key issues being addressed.

• Plan: This section outlines the course of action to address the patient's identified problems. It includes treatment options (medications, therapies, procedures), further diagnostic tests, patient education, referrals to specialists, and follow-up instructions. The plan should be specific, measurable, achievable, relevant, and time-bound (SMART).

The SOAP note structure is widely utilized across various healthcare settings and disciplines, including medicine, nursing, physical therapy, and psychology. Its standardized format promotes clarity, accuracy, and efficient communication within the healthcare team, ultimately contributing to improved patient outcomes.