SOAP note

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The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patient's chart. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.

The length and focus of each component of a SOAP note varies depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status (e.g., it will often be noted whether the patient has passed gas, because if they have, it is considered by many physicians to be safer to allow them to eat.)

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan.

The subjective component describes the patient's current condition in narrative form, usually beginning with the patient's age and gender. It will include all pertinent and negative symptoms.

The objective component includes vital signs, findings from physical examinations, and results from laboratory tests.

The assessment is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely.

The plan is what the health care provider will do to treat the patient's concerns. This should address each item of the differential diagnosis.

A very rough example follows:

S: No Chest Pain or Shortness of Breath. "Feeling better today." Patient reports flatus.

O: [Vital signs, lab data, and physical exam results would be recorded here.]

A: Patient is a 37 year old man on post-operative day 2 for laparoscopic appendectomy, recently passed flatus.

P: Advance diet. Continue to monitor labs. Prepare for discharge home tomorrow morning.

  Plan: Includes, e.g.:
        Diagnostic component (DX Plan: continue to monitor labs),
        Therapeutic component (RX Plan: advance diet),
        Patient education component (PT Educ Plan: none specified above); and,
        Disposition component (DISPO Plan: discharge to home in AM).