SOAP notes stand for Subjective, Objective, Assessment, and Plan. This structured method is widely used by clinicians to document continuing patient encounters, ensuring a comprehensive and organized record of care.
Understanding Each Component of SOAP Notes
The SOAP format provides a standardized way for healthcare professionals to organize information about a patient's health status. Each letter represents a distinct category of information, allowing for clear communication and continuity of care.
Subjective (S)
The 'Subjective' section captures information directly reported by the patient, their family, or caregivers. This includes their chief complaint, symptoms, personal feelings, and any relevant history. It represents the patient's perspective on their condition.
- Key information typically included:
- Chief Complaint (CC): The primary reason the patient is seeking care.
- History of Present Illness (HPI): A detailed description of the current symptoms, including onset, duration, severity, and any aggravating or alleviating factors.
- Past Medical History (PMH): Relevant past illnesses, surgeries, hospitalizations, and chronic conditions.
- Family History (FH) and Social History (SH): Information about family health issues and the patient's lifestyle.
- Review of Systems (ROS): A systematic inquiry about symptoms in various body systems.
Objective (O)
The 'Objective' section contains factual, measurable, and observable data gathered by the healthcare provider. This information is verifiable and reproducible, providing an unbiased view of the patient's condition.
- Key information typically included:
- Vital Signs: Temperature, blood pressure, heart rate, respiratory rate.
- Physical Exam Findings: Results from the clinician's physical examination (e.g., auscultation findings, palpation, inspection).
- Laboratory Results: Blood tests, urine tests, etc.
- Imaging Reports: X-rays, MRI, CT scans.
- Measurements: Weight, height, range of motion.
Assessment (A)
The 'Assessment' component represents the clinician's medical judgment and diagnosis based on the subjective and objective information gathered. This section synthesizes the data to formulate a professional conclusion about the patient's condition.
- Key information typically included:
- Diagnosis (Dx): The clinician's primary and secondary diagnoses.
- Differential Diagnoses: Other possible conditions considered.
- Problem List: A summary of the patient's health concerns.
- Patient Progress: An evaluation of how the patient is responding to treatment or progressing towards goals.
Plan (P)
The 'Plan' outlines the specific course of action the clinician will take to address the patient's issues. This section details the future steps for patient care, guiding the patient and other healthcare team members.
- Key information typically included:
- Treatment Plan: Medications, therapies, procedures.
- Further Diagnostic Tests: Any additional labs or imaging required.
- Referrals: Consultations with specialists.
- Patient Education: Instructions and advice given to the patient.
- Follow-up: Schedule for next appointment or follow-up instructions.
- Goals: Specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient.
Quick Reference Table: SOAP Note Components
| Component | What it Stands For | Description | Example Information |
|---|---|---|---|
| S | Subjective | Patient's reported symptoms, feelings, and history. | "Patient reports lower back pain since yesterday." |
| O | Objective | Observable, measurable data from the clinician. | BP 130/85, HR 78; Lumbar spine tenderness on palpation. |
| A | Assessment | Clinician's diagnosis or impression. | Acute lumbar strain. |
| P | Plan | Next steps for patient care and management. | Prescribe NSAIDs, recommend heat therapy, follow-up in 1 week. |
