A SOAP ( subjective, objective, assessment and plan) note is a type of documentation physicians and other health care providers use to write notes in patient electronic health records or charts. It is also used to share organized information about patients among health professionals.
Deeper dive:
SOAP notes were first used in the 1950s to frame and formalize clinical reasoning in medical records. The subjective component covers a patient’s chief complaint (usually the reason for their visit or hospitalization); the history of present illness (HPI) — including when a medical problem started, how long it’s been happening, and how the person is doing now; medical history; current medications; and allergies.
The objective component includes information that a health care provider observes or measures from the patient, like vital signs or findings from a physical exam, plus relevant imaging or lab test results or other diagnostic data.
The assessment includes the differential diagnosis, other potential diagnoses, possible causes of the medical problem, assessments of the need for therapy, therapy options, etc.
The plan lists what the health care provider will do to treat a patient’s concerns (i.e., ordering labs or an X-ray, referring the person to a specialist, what medications they’ll prescribe, etc.)
If multiple health problems need to be addressed in a SOAP note, the provider will develop a plan for each problem and put them in order of severity/urgency for therapy.
A SOAP (subjective, objective, assessment and plan) note is a type of documentation physicians and other health care providers use to write notes in patient electronic health records or charts. It is also used to share organized information about patients among health professionals.
Deeper dive:
SOAP notes were first used in the 1950s as a means to frame and formalize clinical reasoning in medical records. The subjective component covers a patient’s chief complaint (usually the reason for their visit or hospitalization); the history of present illness (HPI) — including when a medical problem started, how long it’s been happening, and how the person is doing now; medical history; current medications; and allergies.
The objective component includes information that a health care provider observes or measures from the patient, like vital signs or findings from a physical exam, plus relevant imaging or lab test results or other diagnostic data.
The assessment includes the differential diagnosis, other potential diagnoses, possible causes of the medical problem, assessments of the need for therapy, therapy options, etc.
The plan lists what the health care provider will do to treat a patient’s concerns, (i.e., ordering labs or an X-ray, referring the person to a specialist, what medications they’ll prescribe, etc.)
If multiple health problems need to be addressed in a SOAP note, the provider will develop a plan for each problem and put them in order of severity/urgency for therapy.