What does the acronym SOAP stand for in patient note charting?

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. This format is widely used in clinical settings for documenting patient notes to ensure a thorough and organized approach to patient care.

• "Subjective" refers to the patient's reported symptoms and feelings, providing insight into their experience from their own perspective. This includes information gathered from the patient’s own words regarding their health concerns, history, and any other feelings they wish to express.

• "Objective" includes observable and measurable data gathered during the physical examination or from diagnostic tests. This section relies on factual information that the healthcare provider gathers, such as vital signs and laboratory results.

• "Assessment" is the clinician's evaluation of the subjective and objective information, leading to a diagnosis or an understanding of the patient's condition. This part serves to synthesize the information collected and derive conclusions about the patient's health status.

• "Plan" outlines the next steps for the patient's care, including treatment options, referrals, tests that need to be ordered, and education for the patient. It is the plan of action based on the assessment and is crucial for guiding the patient's management.

This structured approach helps healthcare providers maintain clarity and consistency in patient documentation, ultimately supporting improved communication and continuity of care. Other options,