What is a SOAP note?

A SOAP note is a structured method for documenting patient encounters, commonly used in the healthcare field. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which represents the four components of the note.

In the Subjective section, healthcare providers document the patient's verbal description of their symptoms and experiences. The Objective section includes measurable and observable data obtained during the examination, such as vital signs and physical findings. The Assessment is the healthcare provider's interpretation of the patient’s condition, often summarizing the findings and considering the differential diagnoses. Finally, the Plan outlines the proposed management strategies, including further tests, treatments, or referrals.

This systematic approach allows healthcare providers to maintain clear and organized records of patient encounters, facilitating effective communication among medical staff and improving patient care continuity. Other options, such as methods for patient scheduling or financial records, do not capture the essence of a SOAP note, as they focus on administrative or financial aspects rather than the clinical documentation necessary for understanding a patient’s health status.